Test Bank Questions Flashcards
The structure that is responsible for returning oxygenated blood to the heart is the
A. Pulmonary Artery
B. Pulmonary vein
C. Superior Vena Cava
D. Inferior vena cava
ANS: B
The pulmonary vein carries oxygenated blood to the heart. The pulmonary artery carries deoxygenated blood from the heart to the lungs. Both venae cava return blood to the right atrium of the heart.
Chemical receptors that stimulate inspiration are located in the
A. Brain
B. Lungs
C. Aorta
D. Heart
ANS: C
Chemical receptors in the aorta send signals to begin the inspiration process. The brain, lungs, and heart all are affected by this chemical reaction.
The nurse knows that the primary function of the alveoli is to
A. Carry out gas exchange
B. Store Oxygen
C. Regulate tidal volume
D. Produce hemoglobin
ANS: A
The alveolus is a capillary membrane that allows gas exchange of oxygen and carbon dioxide during respiration. The alveoli do not store oxygen, regulate tidal volume, or produce hemoglobin.
- The nurse knows that anemia will result in
a. Hypoxemia.
b. Impaired ventilation.
c. Hypovolemia.
d. Decreased lung compliance.
ANS: A
Patients who are anemic do not have the same level of oxygen-carrying capacity. As a result, oxygen is unable to properly perfuse the tissues, resulting in hypoxemia. Impaired ventilation occurs when oxygen/carbon dioxide exchange occurs at the alveolar level. Hypovolemia is related to decreased circulating blood volume. Lung compliance is related to the elasticity of the lung tissue.
The process of exchanging gases through the alveolar capillary membrane is known as
a. Disassociation.
b. Diffusion.
c. Perfusion.
d. Ventilation.
ANS: B
Diffusion is the process of gases exchanging across the alveoli and capillaries of body tissues. Disassociation is not related to oxygenation. Perfusion is the ability of the cardiovascular system to carry oxygenated blood to tissues and return deoxygenated blood to the heart. Ventilation is the process of moving gases into and out of the lungs.
A nurse caring for a patient who was in a motor vehicle accident that resulted in trauma to C4 would expect to find
a. Decreased tidal volumes.
b. Increased perfusion.
c. Increased use of accessory muscles.
d. Decreased hemoglobin.
ANS: A
A C4 injury would result in damage to the phrenic nerve and would cause a decrease in inspiratory lung expansion. Accessory muscles will also be damaged by a C4 injury. The patient may exhibit decreased perfusion and increased hemoglobin to compensate for hypoxemia.
The nurse would expect to see increased ventilations if a patient exhibits
a. Increased oxygen saturation.
b. Decreased carbon dioxide levels.
c. Decreased pH.
d. Increased hemoglobin levels.
ANS: C
Retained CO2 creates H+ byproducts that lower pH. This sends a chemical signal to increase respiratory rate and would result in increased ventilation. All other options would cause the ventilation rate to normalize or decrease to increase carbon dioxide retention or as the result of delivery of higher levels of oxygen to tissues.
The nurse recommends that a patient install a carbon monoxide detector in the home because
a. It is required by law.
b. Carbon monoxide tightly bonds to hemoglobin, causing hypoxia.
c. Carbon monoxide signals the cerebral cortex to cease ventilations.
d. Carbon monoxide combines with oxygen in the body and produces a deadly toxin.
ANS: B
Carbon monoxide has a higher affinity for hemoglobin; therefore, oxygen is not able to bond to hemoglobin and be transported to tissues. A carbon monoxide detector is not required by law, does not signal the cerebral cortex to cease ventilations, and does not combine with oxygen but with hemoglobin to produce a toxin.
While performing an assessment, the nurse hears crackles in the patient’s lung fields. The nurse also learns that the patient is sleeping on three pillows. What do these symptoms most likely indicate?
a. Left-sided heart failure
b. Right-sided heart failure
c. Atrial fibrillation
d. Myocardial ischemia
ANS: A
Left-sided heart failure results in pulmonary congestion, the signs and symptoms of which include shortness of breath, crackles, and discomfort when lying supine. Right-sided heart failure is systemic and results in peripheral edema and hepatojugular distention. Atrial fibrillation results in an irregular heart rate. Myocardial ischemia most often results in chest pain, along with shortness of breath, nausea, and fatigue.
The nurse knows that a myocardial infarction is an occlusion of what blood vessel?
a. Pulmonary artery
b. Ascending aorta
c. Coronary artery
d. Carotid artery
ANS: C
A myocardial infarction is the lack of blood flow due to obstruction to the coronary artery, which supplies the heart with blood. The ascending aorta is a vessel that leads from the heart to perfuse the brain. The pulmonary artery supplies blood to the lungs. The carotid artery supplies blood to the brain.
Myocardial blood flow is unidirectional; the nurse knows that the correct pathway is which of the following?
a. Right atrium, right ventricle, left ventricle, left atrium
b. Right atrium, left atrium, right ventricle, left ventricle
c. Right atrium, right ventricle, left atrium, left ventricle
d. Right atrium, left atrium, left ventricle, right ventricle
ANS: C
Unoxygenated blood flows through the venae cavae into the right atrium, where it is pumped down to the right ventricle; the blood is then pumped out the pulmonary artery and is returned oxygenated via the pulmonary vein to the left atrium, where it flows to the left ventricle and is pumped out to the rest of the body via the aorta.
The nurse caring for a patient with ischemia to the left coronary artery would expect to find
a. Increased ventricular diastole.
b. Increased stroke volume.
c. Decreased preload.
d. Decreased afterload.
ANS: D
The left coronary artery supplies the muscles of the left ventricle; the strength of the muscle affects the contractility of the heart. The other options are not impacted by the muscles of the left ventricle.
Normal cardiac output is 4 to 6 L/min in a healthy adult at rest. Which of the following is the correct formula to calculate cardiac output?
a. Stroke volume ´ Heart rate
b. Stroke volume/Body surface area
c. Body surface area ´ Cardiac index
d. Heart rate/Stroke volume
ANS: A
Cardiac output can be calculated by multiplying the stroke volume and the heart rate. The other options are not measures of cardiac functioning.
A patient’s heart rate increased from 80 bpm to 160 bpm. The nurse knows that what will follow is a(n)
a. Increase in diastolic filling time.
b. Decrease in cardiac output.
c. Increase in stroke volume.
d. Increase in contractility.
An increased heart rate would decrease the diastolic filling time and stroke volume, thus decreasing overall cardiac output. A decrease in cardiac output results from decreased stroke volume and/or decreased heart rate. An increase in stroke volume and contractility would cause a decrease in heart rate to maintain cardiac output.
The nurse is careful to monitor a patient’s cardiac output because this helps the nurse to determine
a. Peripheral extremity circulation.
b. Oxygenation requirements.
c. Cardiac arrhythmias.
d. Ventilation status.
ANS: A
Cardiac output indicates how much blood is being circulated systemically. Oxygen status would be determined by pulse oximetry and the presence of cyanosis. Cardiac arrhythmias are an electrical impulse monitored through 5-lead ECG. Ventilation status is not solely dependent on cardiac output.
A nurse is assisting a patient with ambulation. The patient becomes short of breath and begins to complain of sharp chest pain. Which action by the nurse is the first priority?
a. Call for the emergency response team to bring the defibrillator.
b. Have the patient sit down in the nearest chair.
c. Return the patient to the room and apply 100% oxygen.
d. Ask a coworker to get the ECG machine STAT.
ANS: B
The patient is experiencing cardiac distress for reasons unknown. The nurse should first secure the safety of the patient and decrease the workload on the patient’s heart by putting him in a resting position; this will increase cardiac output by decreasing after load. Once the patient is stable, the nurse can obtain oxygen to put on the patient. Next, the nurse can begin to monitor the patient’s oxygen and cardiac status. If necessary, the emergency team may be activated to defibrillate.
A patient has inadequate stroke volume related to decreased preload. The nurse anticipates
a. Placing the patient on oxygen monitoring.
b. Administering vasodilators.
c. Verifying that the blood consent form has been signed.
d. Preparing the patient for dialysis.
ANS: C
Preload is affected by the circulating volume; if the patient has decreased fluid, it will need to be replaced with fluid or blood therapy. Before administering blood products, a type and match should be preformed. Monitoring the patient’s oxygenation status will not affect preload. Administering vasodilators affects afterload. Dialysis would further remove fluid from the patient, thus decreasing preload.
When caring for a patient with atrial fibrillation, the nurse is most concerned with which vital sign?
a. Heart rate
b. Pain
c. Oxygen saturation
d. Blood pressure
ANS: C
Atrial fibrillation results in pooling of blood in the atria, forming emboli that can be pumped out to the rest of the body. The most common manifestations are stroke, myocardial infarction, and pulmonary embolus. A sudden and drastic drop in oxygenation and blood pressure can indicate both pulmonary embolus and myocardial infarction.
The nurse would expect a patient with right-sided heart failure to have which of the following?
a. Peripheral edema
b. Basilar crackles
c. Chest pain
d. Cyanosis
ANS: A
Right-sided heart failure results from inability of the right side of the heart to pump effectively, leading to a systemic backup. Peripheral edema and hepatojugular distention are signs of right-sided failure. Basilar crackles can indicate pulmonary congestion from left-sided heart failure. Cyanosis and chest pain result from inadequate tissue perfusion.
The P wave is represented by which portion of the conduction system?
a. SA node
b. AV node
c. Bundle of HIS
d. Purkinje network
ANS: A
The SA node initiates electrical conduction through the atria. The AV node conducts down through the bundle of HIS and the Purkinje network to cause ventricular contraction.
Which statement by the patient indicates an understanding of atelectasis?
a. “It is important to do breathing exercises every hour to prevent atelectasis.”
b. “If I develop atelectasis, I will need a chest tube to drain excess fluid.”
c. “Atelectasis affects only those with chronic conditions such as emphysema.”
d. “Hyperventilation will open up my alveoli, preventing atelectasis.”
ANS: A
Atelectasis develops when alveoli do not expand. Breathing exercises increase lung volume and open the airways. Deep breathing opens the pores of Kohn between the alveoli to allow sharing of oxygen between alveoli. This prevents atelectasis from developing.
The nurse is caring for an African American patient with COPD. The nurse knows that the best location to assess for hypoxia is the
a. Nailbeds.
b. Oral mucosa.
c. Earlobe.
d. Lower extremities.
ANS: B
Because of skin pigmentation, translucent areas of high blood flow such as mucous membranes are best to check for cyanosis, which is a sign of hypoxia. It is important to remember that cyanosis is a late sign of hypoxia.
A nurse is caring for a patient whose temperature is 100.2° F. The nurse expects this patient to hyperventilate owing to
a. Increased metabolic demands.
b. Anxiety over illness.
c. Decreased drive to breathe.
d. Infection destroying lung tissues.
ANS: A
Fever increases the metabolic demands of the body, increasing production of carbon dioxide. The body hyperventilates to get rid of excess carbon dioxide. Anxiety can cause hyperventilation, but this is not the direct cause from a fever. Hyperventilation decreases the drive to breathe. The cause of the fever in this question is unknown.
What assessment finding is the earliest sign of hypoxia?
a. Restlessness
b. Decreased blood pressure
c. Cardiac dysrhythmias
d. Cyanosis
ANS: A
Hypoxia is due to inadequate tissue oxygen at the cellular level. The earliest sign of hypoxia is restlessness; as it progresses, mental status changes, cardiac changes, and cyanosis can occur. Early hypoxia results in an elevated blood pressure. In later hypoxia, vital sign changes such as increased heart and respiratory rate occur. Cyanosis is a late sign of hypoxia.
A 5-year-old who has strep throat was given aspirin for fever. The nurse knows to expect which change in the child’s respiratory pattern?
a. Hyperventilation to decrease serum levels of carbon dioxide
b. Hypoventilation to compensate for metabolic alkalosis
c. Flail chest to decrease the work of breathing
d. Shallow respirations to decrease serum pH
ANS: A
Aspirin causes an increase in carbon dioxide; the body compensates for this by increasing ventilations to blow off excess CO2. Hypoventilation would cause the body to retain even more carbon dioxide and therefore respiratory acidosis. Flail chest occurs with trauma to the chest wall. Shallow respirations would increase serum pH.
A nurse is caring for a patient who suffered a myocardial infarction to the left coronary artery. Upon assessment, the nurse expects to find
a. Blood in the sputum.
b. Distended jugular vein.
c. Peripheral edema.
d. Crackles in the lungs.
ANS: D
The left coronary artery supplies the left ventricle of the heart; damage to the muscle in the left ventricle leads to pulmonary congestion and frothy sputum, and crackles may be heard. A distended jugular vein and peripheral edema are associated with damage to the right side of the heart. Blood in the sputum is indicative of an infection such as tuberculosis.
A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what he should eat for breakfast, what should the nurse recommend?
a. A bowl of cereal with whole milk and a banana
b. A cup of nonfat yogurt with granola, and a handful of dried apricots
c. Whole wheat toast with butter, a side of cottage cheese
d. Omelet with sausage, cheese, and onions
ANS: B
Diets high in potassium, fiber, and calcium and low in fat are best for someone who is managing hypertension. Nonfat yogurt with granola is a good source of calcium, fiber, and potassium; dried apricots add a second source of potassium. Although cereal and a banana provide fiber and potassium, skim milk should be substituted for whole milk to decrease fat. An omelet with sausage and cheese is high in fat. Butter is high in fat.
Upon auscultation, the nurse hears a whooshing sound at the fifth intercostal space. The nurse recognizes that this sound is
a. The beginning of the systolic phase.
b. The opening of the aortic valve.
c. S3, the third heart sound.
d. Regurgitation of the mitral valve.
ANS: D
A whooshing sound at the fifth intercostal space is a murmur; a prolapsed valve allows regurgitation that is heard as a whooshing sound. The systolic phase begins with ventricular filling and closing of the aortic valve, which is heard as the first heart sound, S1. The third heart sound, S3, is heard with heart failure.
A nurse caring for a patient with COPD knows that which oxygen delivery device is most appropriate?
a. Nasal cannula
b. Simple face mask
c. Partial non-rebreather mask
d. Non-rebreather mask
ANS: A
Nasal cannulas deliver oxygen from 1 to 6 L/min. A patient with COPD should never receive more than 3 L/min because this decreases the drive to breathe, resulting in hypoventilation. All other devices are intended for flow rates greater than 6 L/min.
The nurse needs to closely monitor the oxygen status of an elderly patient undergoing anesthesia because of which age-related change?
a. Decreased lung defense mechanisms may cause ineffective airway clearance.
b. Thickening of the heart muscle wall decreases cardiac output.
c. Decreased lung capacity makes proper anesthesia induction more difficult.
d. Alterations in mental status prevent patients’ awareness of ineffective breathing.
ANS: A
The age-related change that would affect airway clearance is decreased defense mechanisms, whereby the patient will have difficulty excreting anesthesia gas. The nurse needs to monitor the patient’s oxygen status carefully to make sure the patient does not retain too much of the drug. Heart muscle thickening and mental status do not affect oxygenation in patients undergoing anesthesia. Lung capacity is not related to anesthesia induction.
The nurse determines that an elderly patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient?
a. Encourage the patient to stay up to date on all vaccinations.
b. Inform the patient of the importance of finishing the entire dose of antibiotics.
c. Schedule patient to get annual tuberculosis skin testing.
d. Create an exercise routine to run 30 minutes every day.
ANS: A
A nursing care plan for preventative health measures should be reasonable and feasible. Keeping up to date on vaccinations is important because vaccine reduces the severity of illnesses and serious complications. Although it is important to finish the full course of antibiotics, it is not a preventative health measure. Scheduling annual tuberculosis skin tests does not address prevention. The exercise routine should be reasonable to increase compliance.
The nurse would expect which change in cardiac output for a patient with fluid volume overload?
a. Increased preload
b. Decreased afterload
c. Decreased tissue perfusion
d. Increased heart rate
ANS: A
Preload refers to the stretch of the ventricle related to the volume of blood; an increase in circulating volume would increase the preload of the heart. Afterload refers to resistance; increased pressure would lead to increased resistance, and afterload would increase. A decrease in tissue perfusion would be seen with hypovolemia. A decrease in fluid volume would cause an increase in heart rate as the body is attempting to increase cardiac output.
A nurse is caring for a patient with COPD who is in recovery for a myocardial infarction. Which of the following nursing actions is the priority?
a. Place the patient on continuous cardiac monitoring.
b. Put the patient on 6 L/min of oxygen via nasal cannula.
c. Deep suction the patient every 2 hours.
d. Assess bilateral lung sounds every hour.
ANS: A
A patient who has a recent myocardial infarction can convert back to a deadly rhythm and needs to be placed on continuous cardiac monitoring. The patient has COPD and should not be placed on oxygen over 4 L/min. Proper cardiac functioning will allow oxygenated blood to be distributed to tissues. Patients with recent myocardial infarction should not be suctioned. This patient does not have any indicators to warrant hourly assessment of lung fields.
The nurse expects a patient with angina pectoris to
a. Experience feelings of indigestion after eating a heavy meal.
b. Have decreased oxygen saturation during rest.
c. Hyperventilate during periods of acute stress.
d. Complain of tingling in the left arm that lasts throughout the morning.
ANS: A
Angina pectoris is chest pain that results from limited oxygen supply. Often pain is precipitated by activities such as exercise, stress, and eating a heavy meal and lasts from 1 to 15 minutes. Hyperventilation may occur to compensate for decreased oxygen perfusion. Symptoms of angina pectoris are relieved by rest and/or nitroglycerin. Oxygen saturation, pain, and tingling in the arm should be relieved by rest. Pain or arm tingling that persists could be a sign of myocardial infarction.
A nonmodifiable risk factor for lung disease is
a. Allergies.
b. Smoking.
c. Stress.
d. Asbestos exposure.
ANS: A
A nonmodifiable risk factor is one the patient has no control over. The patient can manage her allergies but cannot control her immune-mediated responses. Smoking, stress, and asbestos exposure are all modifiable risk factors.
- The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best addresses a short-term goal that the patient could achieve?
a. Running 30 minutes every morning
b. Stopping smoking immediately
c. Sleeping on two to three pillows at night
d. Limiting the diet to 1500 calories a day
ANS: C
To achieve a short-term goal, the nurse should plan a lifestyle change that the patient can make immediately that will have a quick effect. Sleeping on several pillows at night will immediately relieve orthopnea and open the patient’s airway, thereby reducing sleep apnea and reducing fatigue. Running 30 minutes a day will improve cardiopulmonary health, but a patient needs to build up exercise tolerance. Smoking cessation is another process that many people have difficulty doing immediately. It often occurs as a slow progression, beginning with reduction of frequency. A more realistic short-term goal would be to gradually reduce the number of cigarettes smoked. Limiting caloric intake can help a patient lose weight, but this is a gradual process and is not reasonable for a short-term goal.
A nurse is caring for a patient with left sided hemiparesis who has developed bronchitis and has a heart rate of 105, blood pressure of 156/90, and a respiration rate of 30. Which nursing diagnosis is the priority for this patient?
a. Activity intolerance
b. Risk for skin breakdown
c. Impaired gas exchange
d. Risk for infection
ANS: C
The most important nursing intervention is to maintain airway and circulation for this patient; therefore, Impaired gas exchange is the first nursing priority. Activity intolerance is a concern but is not the priority in this case. Risk for skin breakdown and Risk for infection are also important but do not address an immediate impairment with physiologic integrity.
Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an elderly patient?
a. Assist patient to cough, turn, and deep breathe every 2 hours.
b. Encourage patient to drink through a straw to prevent aspiration.
c. Discontinue humidification delivery device to keep excess fluid from lungs.
d. Monitor oxygen saturation, and frequently assess lung bases.
ANS: A
The goal of the nursing action should be the prevention of pneumonia; the action that best addresses this is to cough, turn, and deep breathe to keep secretions from pooling at the base of the lungs. Drinking through a straw increases the risk of aspiration. Humidification thins respiratory secretions, making them easier to expel. Monitoring oxygen status is important but is not a method of prevention.
The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the physician?
a. Clubbing of the fingers
b. Increased anterior-posterior diameter of the chest
c. Hemoptysis
d. Tachypnea
ANS: C
Hemoptysis is an abnormal occurrence of emphysema, and further diagnostic studies are needed to determine the cause of blood in the sputum. Clubbing of the fingers, barrel chest, and tachypnea are all normal findings in a patient with emphysema.
A patient with COPD asks the nurse why he is having increased difficulty with his fine motor skills, such as buttoning his shirt. Which response by the nurse is most therapeutic?
a. “Your body isn’t receiving enough oxygen to send down to your fingers; this causes them to club and makes dexterity difficult.”
b. “Your disease process makes even the smallest tasks seem exhausting. Try taking a nap before getting dressed.”
c. “Often patients with your disease lose mental status and forget how to perform daily tasks.”
d. “Your disease affects both your lungs and your heart, and not enough blood is being pumped. So you are losing sensory feedback in your extremities.”
ANS: A
Clubbing of the nail bed is a frequent symptom of COPD and can make activities of daily living difficult. Taking a nap decreases fatigue but does not help the patient perform fine motor skills. Loss of mental status is not a normal finding with COPD. Low oxygen not low circulating blood volume is the problem in COPD.
A patient with a pneumothorax had a chest tube inserted and was placed on low constant suction. Which finding requires immediate action by the nurse?
a. Fifty milliliters of blood gushes into the drainage device after the patient coughs.
b. The patient complains of pain at the chest tube insertion site that increases with movement.
c. No bubbling is present in the suction control chamber of the drainage device.
d. Yellow purulent discharge is seen leaking out from around the dressing site.
ANS: C
No bubbling in the suction control chamber indicates an obstruction of the drainage system. An obstruction causes increased pressure, which can cause a tension pneumothorax, which can be life threatening. The nurse needs to determine whether the leak is inside the thorax or in the tubing and act from there. Occasional blood gushes from the lung owing to lung expansion, as during a cough; this is reserve drainage. Drainage over 100 mL/hr after 24 hours of chest tube placement is cause for concern. Yellow purulent drainage indicates an infection that should be reported to the physician but is not immediately life threatening.
The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance?
a. Suctioning respiratory secretions several times every hour
b. Administering humidified oxygen through a tracheostomy collar
c. Instilling normal saline into the tracheostomy to thin secretions before suctioning
d. Deflating the tracheostomy cuff before allowing the patient to cough up secretions
ANS: B
Humidification of air will help keep the mucous membranes moist and will make secretions easier to expel. Suctioning should be done only as needed; too frequent suctioning can damage the mucosal lining, resulting in thicker secretions. Normal saline should never be instilled into a tracheostomy because this could lead to infection. The purpose of the tracheostomy cuff is to keep secretions from entering the lungs; the nurse should not deflate the tracheostomy cuff unless instructed to do so by the physician.
The nurse is educating a student nurse on caring for a patient with a chest tube. The nurse knows that teaching has been effective when the student states
a. “I should strip the drains on the chest tube every hour to promote drainage.”
b. “If the chest tube becomes dislodged, the first thing I should do is notify the physician.”
c. “I should clamp the chest tube when giving the patient a bed bath.”
d. “I should report if I see continuous bubbling in the water-seal chamber.”
ANS: D
Correct care of a chest tube involves knowing normal and abnormal functioning of the tube. Bubbling in the water-seal chamber is expected. Stripping the drain requires a physician order. If the chest tube becomes dislodged, immediately apply occlusive pressure over the insertion site. The chest tube should not be clamped unless necessary; if so, the length of time clamped would be minimal to reduce the risk of pneumothorax.
Which nursing diagnosis is the priority when caring for a patient with a traumatic brain injury who had a tracheostomy placed?
a. Risk for skin breakdown
b. Impaired gas exchange
c. Ineffective airway clearance
d. Risk for infection
ANS: C
Patients with tracheotomies rely on the tracheostomy to provide a stable open airway. The nurse is most concerned about a dementia patient who is extubating himself unknowingly. The nurse is also concerned that the patient would not be able to cough up his own secretions and could occlude the tracheostomy, putting him at risk for Ineffective airway clearance. Nursing priorities are airway, breathing, and circulation. Frequently occurring nursing diagnoses should be addressed before “Risk” diagnoses. Skin breakdown and infection are not immediately life threatening.
The nurse knows that the most effective method for suctioning a patient with a tracheostomy tube is to
a. Set suction regulator at 150 to 200 mm Hg.
b. Liberally lubricate the end of the suction catheter with a water-soluble solution.
c. Limit the length of suctioning to 10 to 15 seconds.
d. Apply suction while gently rotating and inserting the catheter.
ANS: C
Suctioning passes should be limited to 10 to 15 seconds to avoid oxygen desaturation. Suction for a tracheostomy should be set at 100 to 150 mm Hg. Excessive lubrication can clog the catheter or occlude the airway. Suction should not be applied until after the catheter has been inserted.
The nurse is assessing a patient with a right pneumothorax. Which finding would the nurse expect?
a. Bilateral expiratory crackles
b. Absence of breath sounds on the right side
c. Right-sided wheezes on inspiration
d. Trachea deviated to the right
ANS: B
A right pneumothorax is a collapsed lung; therefore, no breath sounds should be heard on that side. Crackles indicate pneumonia. Wheezes are asthma related. A collapsed right lung would cause the trachea to deviate to the left.
The nurse knows that a closed suction device would be most appropriate for which patient?
a. A 5-year-old with an asthma attack following severe allergies
b. A 24-year-old with a right pneumothorax following a motor vehicle accident
c. A 50-year-old with pulmonary edema following a myocardial infarction
d. A 75-year-old with aspiration pneumonia following a stroke
ANS: D
Suctioning is most appropriate for someone with increased lung secretions who may have difficulty getting them up on their own. In this case, the stroke patient would have decreased coughing abilities and already has a diagnosis of pneumonia. The 5-year-old child would benefit from an inhaler. A chest tube is needed for the pneumothorax. Suctioning is contraindicated in patients with a myocardial infarction.
While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. What is the nurse’s first nursing action?
a. Press the emergency response button.
b. Place the patient on a face mask delivering 100% oxygen.
c. Insert a spare tracheostomy without the obturator.
d. Manually occlude the tracheostomy with sterile gauze.
ANS: C
The nurse’s first priority is to establish a stable airway by inserting a spare trach into the patient’s airway; ideally an obturator should be used, but it is not life threatening to omit this. The nurse could activate the emergency response team if the patient is still unstable after the tracheostomy is placed. A patient with a tracheostomy has an impairment that causes him not to be able to breathe normally; a face mask would not be an effective method of getting air into the lungs. Manually occluding pressure over the tracheostomy site is not appropriate.
Approximately two thirds of the body’s total water volume exists in the _____ fluid.
a.
Intracellular
b.
Interstitial
c.
Intravascular
d.
Transcellular
ANS: A
Intracellular fluid accounts for approximately two thirds of the fluids in the body—about 42% of total body weight. Interstitial fluid, intravascular fluid, and transcellular fluid constitute extracellular fluid, which is the fluid outside a cell.
The process of passively moving water from an area of lower particle concentration to an area of higher particle concentration is known as
a.
Hydrolysis.
b.
Osmosis.
c.
Filtration.
d.
Active transport.
ANS: B
The process of moving water from an area of low particle concentration to an area of higher particle concentration is known as osmosis. Hydrolysis is not a term related to fluid and electrolyte balance. Filtration is mediated by fluid pressure from an area of higher pressure to an area of lower pressure. Active transport requires metabolic activity and is not passive.
The nurse knows that edema in a patient who has venous congestion from right heart failure is facilitated by an imbalance with regard to _____ pressure.
a.
Hydrostatic
b.
Osmotic
c.
Oncotic
d.
Concentration
ANS: A
Venous congestion increases capillary hydrostatic pressure. Increased hydrostatic pressure causes edema by causing increased movement of fluid into the interstitial area. Osmotic and oncotic pressures involve the concentrations of solutes and can contribute to edema in other situations. Concentration pressure is not a nursing term.
The nurse understands that administering a hypertonic solution to a patient will shift water from the _____ to the _____ space.
a.
Intracellular; extracellular
b.
Extracellular; intracellular
c.
Intravascular; intracellular
d.
Intravascular; interstitial
ANS: A
A hypertonic solution has a concentration greater than normal body fluids, so water will shift out of cells because of the osmotic pull of the extra particles. Movement of water into cells occurs when hypotonic fluids are administered. Distribution of fluid between intravascular and interstitial spaces occurs by filtration, the net sum of hydrostatic and osmotic pressures.
Which patient is most at risk for sensible water loss?
a.
A 7-year-old child with asthma
b.
A 24-year-old adult with constipation
c.
A 56-year-old patient with gastroenteritis
d.
An 80-year-old patient with pneumonia
ANS: D
Sensible water loss consists of fluids lost from the skin through visible perspiration, such as with a resolving fever related to pneumonia. Asthma would be insensible water loss through respiration. Gastroenteritis causes diarrhea with its large volume loss. Constipation does not affect fluid loss.
The nurse knows that the most abundant cation in the blood is
a.
Sodium.
b.
Potassium.
c.
Chloride.
d.
Magnesium.
ANS: A
Sodium is the most abundant cation in the blood. Potassium is the predominant intracellular cation. Chloride is an anion (negatively charged) rather then a cation (positively charged). Magnesium is found predominantly inside cells and in bone.
The nurse receives the patient’s most recent blood work results. Which laboratory value is of greatest concern?
a.
Sodium of 145 mEq/L
b.
Calcium of 17.5 mg/dL
c.
Potassium of 3.5 mEq/L
d.
Chloride of 100 mEq/L
ANS: B
Normal calcium range is 8.5 mg/dL to 10.5 mg/dL; therefore, a value of 17.5 mg/dL is abnormally high and of concern. The rest of the laboratory values are within their normal ranges: sodium 135 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L; chloride 98 to 106 mEq/L.
The nurse would expect a patient with increased levels of serum calcium to also have _____ levels.
a.
Increased potassium
b.
Decreased phosphate
c.
Decreased sodium
d.
Increased magnesium
ANS: B
Serum calcium and phosphate have an inverse relationship. When one is elevated, the other decreases, except in some patients with end-stage renal disease. Increased serum calcium would not necessarily cause changes in levels of potassium, sodium, or magnesium.
The nurse knows that an imbalance of which ion causes acid-base impairment?
a.
Hydrogen
b.
Calcium
c.
Magnesium
d.
Sodium
ANS: A
The concentration of hydrogen ions determines pH. Low pH designates an acidic environment. High pH designates an alkaline environment. Calcium, magnesium, and sodium are ions, but their imbalances are not direct acid-base impairments.
The nurse would expect a patient with respiratory acidosis to have an excessive amount of
a.
Carbon dioxide.
b.
Bicarbonate.
c.
Oxygen.
d.
Phosphate.
ANS: A
Respiratory acidosis occurs when the lungs are not able to excrete enough carbon dioxide. Carbon dioxide and water create carbonic acid. A buildup of carbonic acid causes the ECF to become more acidic, decreasing the pH. Bicarbonate is normal with uncompensated respiratory acidosis or elevated with compensated respiratory acidosis. Excessive oxygen and phosphate are not characteristic of respiratory acidosis.
A 2-year-old child was brought into the emergency department after ingesting several morphine tablets from a bottle in his mother’s purse. The nurse knows that the child is at greatest risk for which acid-base imbalance?
a.
Respiratory acidosis
b.
Respiratory alkalosis
c.
Metabolic acidosis
d.
Metabolic alkalosis
ANS: A
Morphine overdose can cause respiratory depression and hypoventilation. Hypoventilation results in retention of CO2 and respiratory acidosis. Respiratory alkalosis would result from hyperventilation, causing a decrease in CO2 levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting, diarrhea, or other conditions that affect metabolic acids.
A patient was admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. The patient’s respiratory rate has decreased to 12 breaths per minute. The nurse would expect the patient to have which of the following arterial blood gas values?
a.
pH 7.78, PaCO2 40 mm Hg, HCO3– 30 mEq/L
b.
pH 7.52, PaCO2 48 mm Hg, HCO3– 28 mEq/L
c.
pH 7.35, PaCO2 35 mm Hg, HCO3– 26 mEq/L
d.
pH 7.25, PaCO2 47 mm Hg, HCO3– 29 mEq/L
ANS: B
Compensated metabolic alkalosis should show alkalosis pH and HCO3– (metabolic) values, with a slightly acidic CO2 (compensatory respiratory acidosis). In this case, pH 7.52 is alkaline (normal = 7.35 to 7.45), PaCO2is acidic (normal 35 to 45 mm Hg), and HCO3– is elevated (normal = 22 to 26 mEq/L). A result of pH 7.78, PaCO2 40 mm Hg, HCO3– 30 mEq/L is uncompensated metabolic alkalosis. pH 7.35, PaCO2 35 mm Hg, HCO3– 26 mEq/L is within normal limits. pH 7.25, PaCO2 47 mm Hg, HCO3– 29 mEq/L is compensated respiratory acidosis.
The nurse would not expect full compensation to occur for which acid-base imbalance?
a.
Respiratory acidosis
b.
Respiratory alkalosis
c.
Metabolic acidosis
d.
Metabolic alkalosis
ANS: B
Usually the cause of respiratory alkalosis is a temporary event (e.g., an asthma or anxiety attack). The kidneys take about 24 hours to compensate for an event, so it is unlikely to see much if any compensation for respiratory alkalosis. Respiratory acidosis usually results from longer-term conditions such as chronic lung disease, narcotic overdose, or another event that causes respiratory depression. The kidneys still do not respond for about 24 hours, but usually the event is still occurring. For both metabolic imbalances, the respiratory system is quick to attempt to compensate: however, it may have difficulty sustaining that compensation.
A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment finding would the nurse expect?
a.
Thready peripheral pulses
b.
Abdominal distention
c.
Dry mucous membranes
d.
Flushed skin
ANS: B
Signs and symptoms of hypokalemia are muscle weakness and fatigue, abdominal distention, decreased bowel sounds, and cardiac dysrhythmias. Thready peripheral pulses indicate hypovolemia. Dry mucous membranes and flushed skin are indicative of dehydration and hypernatremia.
In which patient would the nurse expect to see a positive Chvostek sign?
a.
A 7-year-old child admitted for severe burns
b.
A 24-year-old adult admitted for chronic alcohol abuse
c.
A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism
d.
A 75-year-old patient admitted for a broken hip related to osteoporosis
ANS: B
A positive Chvostek sign is representative of hypocalcemia or hypomagnesemia. Hypomagnesemia is common with alcohol abuse. Hypocalcemia can be brought on by alcohol abuse and pancreatitis (which also can be affected by alcohol consumption). Burn patients frequently experience ECV deficit. Hyperparathyroidism causes hypercalcemia. Immobility is associated with hypercalcemia.
Which organ system is responsible for compensation of respiratory acidosis?
a.
Respiratory
b.
Renal
c.
Gastrointestinal
d.
Endocrine
ANS: B
The kidneys are responsible for respiratory acidosis compensation. A problem with the respiratory system causes respiratory acidosis, so another organ system (renal) needs to compensate. Problems with the gastrointestinal and endocrine systems can cause acid-base imbalances, but these systems cannot compensate for an existing imbalance.
Which laboratory value should the nurse examine when evaluating uncompensated respiratory alkalosis?
a.
PaO2
b.
Anion gap
c.
PaCO2
d.
HCO3–
ANS: C
Uncompensated respiratory imbalances are seen in the PaCO2 levels. PaO2 indicates oxygen status. Anion gap is used for metabolic acidosis. HCO3– is used to evaluate compensation for respiratory imbalances or uncompensated metabolic imbalances.
The nurse is caring for a diabetic patient in renal failure. Which laboratory findings would the nurse expect?
a.
pH 7.3, PaCO2 36 mm Hg, HCO3– 19 mEq/L
b.
pH 7.5, PaCO2 35 mm Hg, HCO3– 35 mEq/L
c.
pH 7.3, PaCO2 47 mm Hg, HCO3– 23 mEq/L
d.
pH 7.35, PaCO2 40 mm Hg, HCO3– 25 mEq/L
ANS: A
Patients in renal failure develop metabolic acidosis. The laboratory values that reflect this are pH 7.3, PaCO2 36 mm Hg, HCO3– 19 mEq/L. A laboratory finding of pH 7.5, PaCO2 35 mm Hg, HCO3– 35 mEq/L is metabolic alkalosis. pH 7.3, PaCO2 47 mm Hg, HCO3– 23 mEq/L is respiratory acidosis. pH 7.35, PaCO2 40 mm Hg, HCO3– 25 mEq/L values are within normal range.
The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. The nurse gives the patient a diuretic. What electrolyte imbalance is the nurse most concerned about?
a.
Potassium imbalance
b.
Sodium imbalance
c.
Calcium imbalance
d.
Phosphate imbalance
ANS: A
Using a diuretic can cause excess excretion of potassium, unless it is a potassium-sparing diuretic. The other electrolytes are not excreted in the same way with diuretics.
A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate?
a.
“Are you having difficulty sleeping at night?”
b.
“How many calories a day do you consume?”
c.
“Do you have dry mouth or feel thirsty?”
d.
“How many times a day do you urinate?”
ANS: D
A rapid gain in weight usually indicates ECV excess if the person began with normal ECV. Asking the patient about urination habits will illuminate whether the body is trying to excrete the excess fluid, or if renal dysfunction is contributing to ECV excess. Difficulty sleeping at night can occur if the body builds up excessive fluid in the lungs; however, it could also mean that the patient is getting up frequently to urinate, so the question is not specific enough. Caloric intake does not account for rapid weight changes. Dry mouth and thirst accompany ECV deficit, which would be associated with rapid weight loss.
Which fluid order should the nurse question for a patient with a traumatic brain injury?
a.
0.45% sodium chloride
b.
0.9% sodium chloride
c.
Lactated Ringer’s
d.
Dextrose 5% in 0.9% sodium chloride
ANS: A
0.45% sodium chloride is a hypotonic solution, and hypotonic solutions cause cells to swell, which can cause increased intracranial pressure. This can be life threatening for a patient with a traumatic brain injury. The other solutions are physiologically isotonic sodium-containing solutions that will expand ECV but will not cause cell swelling. In the fluid container, dextrose 5% in 0.9% sodium chloride is hypertonic, but the dextrose enters cells rapidly, leaving isotonic 0.9% sodium chloride.
The physician asks the nurse to monitor the fluid volume status of a congestive heart failure patient and a patient at risk for clinical dehydration. What is the most effective nursing intervention for monitoring both of these patients?
a.
Weigh the patients every morning before breakfast.
b.
Ask the patients to record their intake and output.
c.
Measure the patients’ blood pressure every 4 hours.
d.
Assess the patients for edema in extremities.
ANS: A
An effective measure of fluid retention or loss is daily weights; each kilogram (2.2 pounds) change is equivalent to 1 liter of fluid gained or lost. This measurement should be performed at the same time every day using the same scale and the same amount of clothing. Although intake and output records are important assessment measures, some patients are not able to keep their own records themselves. Blood pressure can decrease with ECV deficit but will not necessarily increase with recent ECV excess (heart failure patient). Edema occurs with ECV excess but not with clinical dehydration.
A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, elevated white blood cell count, and oral candidiasis. The nurse knows that the purpose of starting total parenteral nutrition (TPN) is to
a.
Replace fluid, electrolytes, and nutrients in the patient.
b.
Stimulate the patient’s appetite to eat.
c.
Provide medication to raise the patient’s blood pressure.
d.
Deliver antibiotics to fight off infection.
ANS: A
Total parenteral nutrition is an intravenous solution composed of nutrients and electrolytes to replace the ones the patient is not eating. TPN does not stimulate the appetite. TPN does not contain blood pressure medication or antibiotics.
A patient presents to the emergency department with the complaint of vomiting and diarrhea for the past 48 hours. The nurse anticipates which fluid therapy initially?
a.
0.9% sodium chloride
b.
Dextrose 10% in water
c.
Dextrose 5% in water
d.
0.45% sodium chloride
ANS: A
Patients with prolonged vomiting and diarrhea become hypovolemic. The best solution to replace extracellular volume is 0.9% sodium chloride, which is an isotonic solution. Dextrose 10% in water, dextrose 5% in water, and 0.45% sodium chloride act as hypotonic solutions in the body. The first consideration is replacing extracellular volume to oxygenate tissues.
A patient with a lower respiratory infection has pH of 7.25, PaCO2 of 55 mm Hg, and HCO3– of 20 mEq/L. The physician has been notified. Which is the priority nursing intervention for this patient?
a.
Check the color of the patient’s urine output.
b.
Place the patient in Trendelenburg position.
c.
Encourage the patient to increase respirations.
d.
Place the patient in high Fowler’s position.
ANS: C
The patient has respiratory acidosis from CO2 retention. Increasing rate and depth of respiration will allow the patient to blow off excess carbon dioxide, and this will begin to correct the imbalance. Checking the urine color is not a necessary assessment. The Trendelenburg position likely would make it more difficult for the patient to breathe and should be avoided. Placing the patient in high Fowler’s position may make the patient more comfortable, but it is not necessary.
The nurse knows that intravenous fluid therapy has been effective for a patient with hypernatremia when
a.
Serum sodium concentration returns to normal.
b.
Systolic and diastolic blood pressure decrease.
c.
Large amounts of emesis and diarrhea decrease.
d.
Urine output increases to 150 mL/hr.
ANS: A
Hypernatremia is diagnosed by elevated serum sodium concentration. Blood pressure is not an accurate indicator of hypernatremia. Emesis and diarrhea will not stop because of intravenous therapy. Urine output is influenced by many factors, including extracellular fluid volume. A large dilute urine output can cause further hypernatremia.
The nurse would select the dorsal venous plexus of the foot as an IV site for which patient?
a.
A 2-year-old child
b.
A 22-year-old adult
c.
A 50-year-old patient
d.
An 80-year-old patient
ANS: A
Use of the foot as an IV site is common in children but is avoided in adults because of the risk for thrombophlebitis.
Which assessment finding should cause a nurse to question administering a sodium-containing isotonic intravenous fluid?
a.
Blood pressure 102/58
b.
Dry mucous membranes
c.
Poor skin turgor
d.
Pitting edema
ANS: D
Pitting edema indicates that the patient may be retaining excess extracellular fluid, and the nurse should question the type of solution meant to rehydrate the patient. All other options are consistent with ECV deficit, and the patient would benefit from a sodium-containing isotonic solution that expands extracellular volume.
A patient is to receive 1500 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. What is the minute flow rate (drops per minute)?
a.
12 gtt/min
b.
24 gtt/min
c.
125 gtt/min
d.
150 gtt/min
ANS: C
Microdrip tubing delivers 60 gtt/mL. Calculation for a rate of 125 mL/hr using microdrip tubing: (125 mL/1 hr)(60 gtt/1 mL)(1 hr/60 min) = 125 gtt/min.
A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 20 mL/hr. At what time should the infusion be completed?
a.
0645 Tuesday
b.
0675 Tuesday
c.
0715 Tuesday
d.
0735 Tuesday
ANS: C
250 mL divided by 20 mL/hr = 12.5 hr
0.5 hr ´ 60 min = 30 min
1845 + 12 hr 30 min = 3115, which would be 0715 on Tuesday, the following day.
A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300 mL output. The patient has voided 400 mL of urine. After reporting these values to the physician, what orders does the nurse anticipate?
a.
Add a potassium supplement to replace loss from output.
b.
Decrease the rate of intravenous fluids to 100 mL/hr.
c.
Discontinue the nasogastric suctioning.
d.
Administer a diuretic to prevent fluid volume excess.
ANS: A
The total fluid intake and output equals 700 mL, which meets the provider goals. Record half the volume of ice chips when calculating intake. Patients with nasogastric suctioning are at risk for potassium deficit, so the nurse would anticipate a potassium supplement to correct this condition. The other measures would be unnecessary because the net fluid volume is equal.
A nurse is caring for a patient who is in hypertensive crisis. When the nurse is flushing the patient’s peripheral IV, the patient complains of pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse’s initial action?
a.
Notify the physician.
b.
Administer pain medication.
c.
Discontinue the IV.
d.
Start a new IV line.
ANS: D
The IV site has phlebitis. The nurse should start a new IV before discontinuing the old one because it is important to always have an IV access site in a patient who is in hypertensive crisis. Then the physician can be notified. Pain medication may or may not need to be administered.
A patient was admitted for hypovolemia and has intravenous fluid running at 250 mL/hr. The patient complains of burning at the IV insertion site. Upon assessment, the nurse does not find redness, swelling, heat, or coolness. The nurse suspects that the
a.
IV has infiltrated.
b.
IV has caused phlebitis.
c.
Fluid is infusing too quickly.
d.
Patient is allergic to the fluid.
ANS: C
The infusion may be flowing faster than the vein can handle, causing discomfort. The nurse should slow down the infusion. Infiltration results in skin that is blanched, cool, and edematous around the IV insertion site. Pain, warmth, erythema, and a palpable venous cord are all symptoms of phlebitis. Allergic response to the fluid could involve a combination of itching, flushing, hypotension, and dyspnea, depending on the severity.
The nurse is caring for a patient with sepsis. The plan of care for the patient is to administer antibiotics 3 times a day for 4 weeks. What device will be used to administer these antibiotics?
a.
A continuous infusion
b.
A heparin locked peripheral catheter
c.
A PICC line
d.
An implanted port catheter
ANS: C
A PICC line is a type of central venous device that can be introduced into a peripheral vein for administration of IV antibiotics for an extended period, over the course of several weeks. A continuous infusion would not take place if the patient received antibiotics only 3 times daily. A peripheral catheter would not be necessary or heparin locked. An implanted port catheter is intended for long-term use of venous access over months, or even years.
A nurse is preparing to administer a blood transfusion. Which assessment finding would the nurse report immediately?
a.
Blood pressure 120/60
b.
Temperature 101.3° F
c.
Poor skin turgor and pallor
d.
Heart rate of 100 beats per minute
ANS: B
A fever should be reported immediately, and the blood transfusion may be postponed. All other assessment findings are acceptable before starting a blood transfusion.
A nurse has just received a bag of packed red blood cells. The nurse knows that the blood must not remain at room temperature for longer than
a.
30 minutes.
b.
1 hour.
c.
2 hours.
d.
4 hours.
ANS: D
Blood should be allowed to sit at room temperature for a maximum of 4 hours. After 4 hours, risk of bacterial contamination of the blood is increased.
A patient had an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, what is the nurse’s next action?
a.
Run normal saline through the existing tubing.
b.
Start normal saline at TKO rate using new tubing.
c.
Discontinue the IV catheter.
d.
Return the blood to the blood bank.
ANS: B
The nurse should first attach new tubing and begin running in normal saline at a rate to keep the vein open, in case any sorts of medications need to be delivered through that IV site. The existing tubing should not be used because that would infuse the blood in the tubing into the patient. It is necessary to preserve the IV catheter in place for IV access to treat the patient. After the patient has been assessed and stabilized, the blood can be returned to the blood bank.
A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. The nurse recognizes that the patient is experiencing which transfusion complication?
a.
Anaphylactic shock
b.
Septicemia
c.
Fluid volume overload
d.
Hemolytic reaction
ANS: C
The signs and symptoms are concurrent with fluid volume overload. Anaphylactic shock would have presented with urticaria, dyspnea, and hypotension. Septicemia would include a fever. A hemolytic reaction would consist of flank pain, chills, and fever.
The nurse selects appropriate tubing for a blood transfusion by ensuring that the tubing has
a.
Two-way valves to allow the patient’s blood to mix and warm the blood transfusing.
b.
An injection port to mix additional electrolytes into the blood.
c.
An air vent to let bubbles in the blood escape.
d.
A filter to ensure that clots do not enter the patient.
ANS: D
All blood transfusions must have a filter to prevent microemboli from being administered to the patient. The patient’s blood should not be aspirated to mix with the infusion blood. The blood should not have air bubbles to vent; if a bag of blood does have bubbles, the nurse should promptly return the blood to the blood bank. The only substance compatible with blood is normal saline; no additives should be mixed with the infusing blood.
The nurse is caring for a patient with hyperkalemia. Which body system would be most important for the nurse plan to monitor closely?
a.
Gastrointestinal
b.
Neurological
c.
Cardiac
d.
Respiratory
ANS: C
Potassium balance is necessary for cardiac function. Hyperkalemia places the patient at risk for potentially serious dysrhythmias. Monitoring of gastrointestinal, neurological, and respiratory systems would be indicated for other electrolyte imbalances.
Which assessment finding would the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?
a.
Lightheadedness when standing up
b.
Weak quadriceps muscles
c.
Tingling of the extremities and tetany
d.
Decreased deep tendon reflexes
ANS: C
This patient has hypocalcemia because the normal calcium range is 8.4 to 10.5 mg/dL. Sodium and potassium values are within their normal ranges: sodium 135 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L. Hypocalcemia causes muscle tetany, positive Trousseau’s sign, and tingling of the extremities. Lightheadedness when standing up is a manifestation of ECV deficit or sometimes hypokalemia. Weak quadriceps muscles are associated with potassium imbalances. Decreased deep tendon reflexes are related to hypercalcemia or hypermagnesemia.
A patient informs the nurse that he has the type of diabetes that does not require insulin. The nurse advises the patient to make which dietary change?
a.
Drink plenty of fluids throughout the day to stay hydrated.
b.
Avoid food high in acid to avoid metabolic acidosis.
c.
Reduce the quantity of carbohydrates ingested to lower blood sugar.
d.
Include a serving of dairy in each meal to elevate calcium levels.
ANS: A
The patient is indicating that he has diabetes insipidus, which places him at risk for dehydration and hypernatremia. Dehydration should be prevented by drinking plenty of fluids to replace the extra water excreted in the urine. Foods high in acid should be avoided in a patient with GERD. A reduction in carbohydrates applies to type 2 diabetes mellitus patients. Calcium-rich dairy products would be recommended for a hypocalcemic patient.
When selecting a site to insert an intravenous catheter on an adult, the nurse should (Select all that apply.)
a.
Start proximally and move distally on the arm.
b.
Choose a vein with minimal curvature.
c.
Choose the patient’s dominant arm.
d.
Check for contraindications to the extremity.
e.
Select a vein that is rigid.
f.
Avoid areas of flexion.
ANS: B, D, F
The nurse should start distally and move proximally, choosing the nondominant arm if possible. The vein should be relatively straight to avoid catheter occlusion. Contraindications to starting an IV catheter are conditions such mastectomy, AV fistula, and central line in the extremity. The nurse should feel for the best location; a good vein should feel spongy, a rigid vein should be avoided because it might have had previous trauma or damage.
Which of the following assessments would indicate that a patient’s IV has infiltrated? (Select all that apply.)
a.
Edema of the extremity near the insertion site
b.
Skin discolored or bruised in appearance
c.
Pain and warmth at the insertion site
d.
Skin cool to the touch
e.
Reddish streak proximal to the insertion site
f.
Numbness or loss of sensation
g.
Palpable venous cord
ANS: A, B, D, F
Infiltration results in skin that is edematous near the IV insertion site. Skin is cool to the touch and may be bruised or discolored, and the patient may experience some numbness. Pain, warmth, erythema, a reddish streak, and a palpable venous cord are all symptoms of phlebitis.
When discontinuing a peripheral IV access, the nurse should (Select all that apply.)
a.
Use scissors to remove the IV site dressing and tape.
b.
Keep the catheter parallel to the skin while removing it.
c.
Apply firm pressure with sterile gauze during removal.
d.
Stop the infusion before removing the IV catheter.
e.
Wear sterile gloves and a mask.
f.
Apply pressure to the site for 2 to 3 minutes after removal.
ANS: B, D, F
The nurse should stop the infusion before removing the IV catheter, so the fluid does not drip on the patient’s skin; keep the catheter parallel to the skin while removing it to reduce trauma to the vein; and apply pressure to the site for 2 to 3 minutes after removal to decrease bleeding from the site. Scissors should not be used because they may accidentally cut the catheter or tubing or may injure the patient. During removal of the IV catheter, light pressure, not firm pressure, is indicated to prevent trauma. Clean gloves are used for discontinuing a peripheral IV access because gloved hands will handle the external dressing, tubing, and tape, which are not sterile.
Caring is central to nursing practice, but technological advances for rapid diagnosis and treatment should lead the nurse to realize that
a.
Technology has replaced caring as nurses’ primary focus.
b.
Technology and caring cannot coexist when related to patient care.
c.
Technology becomes a powerful tool when it works with caring.
d.
Caring is the essence of nursing and is isolated from technology.
ANS: C
Technological advances become dangerous without a context of skillful and compassionate care. It is time to value and embrace caring practices and expert knowledge (technology), which are the heart of competent nursing practice. Neither technology nor caring can stand alone. They must coexist to provide ultimate patient care.
Caring is a universal phenomenon that involves
a.
Being disconnected.
b.
Excluding outside phenomena in favor of family relationships.
c.
Focusing only on human relationships with one another.
d.
What matters to a person.
ANS: D
Caring determines what matters to a person. It underlies a wide range of interactions, from parental love to friendship, from caring for one’s work to caring for one’s pet to caring for and about one’s patients. Caring means that people, events, projects, and things matter to a person. It is a word for being connected.
With respect to the concept of caring, most nursing theories
a.
Embrace the disease orientation to health care as Watson does.
b.
Recognize Leininger’s theory and reject culture as a caring force.
c.
Identify caring as highly relational involving patient and nurse.
d.
Stress the universality of the expression of caring.
ANS: C
Nursing caring theories have common themes. Caring is highly relational. Caregiving relationships open up possibilities or close them down. Watson’s transpersonal caring theory rejects the disease orientation to health care and places care before cure. Leininger stresses the importance of nurses’ understanding of cultural caring behaviors. Caring is very personal, thus expression of caring differs for each patient.
The patient has had a colostomy placed but has not yet been able to look at it. The nurse is given the task of teaching the patient how to care for it. The nurse sits with the patient, and together they form a plan on how to approach dealing with colostomy care. Which caring process is the nurse performing?
a.
Knowing
b.
Doing for
c.
Enabling
d.
Maintaining belief
ANS: C
Enabling is facilitating another’s passage through a life transition and unfamiliar events. Working with the patient to find alternate ways to help him face his fears and perform the task is doing just that. Knowing is striving to understand an event because it has meaning in the life of another. This must be done before enabling can occur. Doing for is doing for the other as he or she would do for self if it were at all possible. The nurse here is not doing for the patient but is helping him find a way that he can do it. Maintaining belief is sustaining faith in the other’s capacity to get through an event or transition and face a future with meaning. This may be an underlying theme to the process but is not what the nurse is actually doing.
In trying to determine patients’ perception of caring, several studies have suggested that
a.
The nurse’s effectiveness in performing tasks defines her profession.
b.
The affective dimension of nursing care is of primary importance.
c.
All patients have the same needs and similar personalities.
d.
Patients value both task performance and the affective dimension of nursing.
ANS: D
Patients continue to value nurses’ effectiveness in performing tasks, but clearly patients value the affective dimension of nursing care. All patients are unique; however, understanding common behaviors that patients associate with caring helps the nurse learn to express caring in practice.
The nurse is admitting a patient who will be having elective surgery. The nurse spends over an hour asking the patient questions as part of the admission process. What is the nurse’s primary reason for doing this?
a.
It is hospital protocol and part of the admission process.
b.
The nurse is trying to make the patient more comfortable.
c.
This will help the nurse provide better care for the patient.
d.
The nurse needs the time to give a detailed description of what to expect.
ANS: C
Focusing on building a relationship that allows the nurse to learn what is important to the patient helps the nurse to identify a patient’s unique perceptions and expectations. Knowing who patients are helps the nurse select caring approaches that are most appropriate to patients’ needs. Learning what is important to patients may determine how much description is needed.
The term “ethics” refers to the ideals of right and wrong behavior. As such, the “ethics of care” creates a professional relationship in which the nurse
a.
Must make decisions for the patient solely using intellectual principles.
b.
Must become the patient’s advocate based on the patient’s wishes.
c.
Uses only analytical principles to determine what is best for the patient.
d.
Must ignore unequal family relationships because they are personal.
ANS: B
An ethic of care places the nurse as the patient’s advocate, solving ethical dilemmas by attending to relationships and by giving priority to each patient’s unique personhood. An ethic of care is unique so that professional nurses do not make professional decisions based solely on intellectual or analytical principles. Instead, an ethic of care places “caring” at the center of decision making. Nurses who function from an ethic of care are sensitive to unequal relationships that lead to abuse of one person’s power over another—intentional or otherwise.
Providing “presence” involves “being there” and “being with.” What does this involve?
a.
Closeness and a sense of caring
b.
Focusing on the task that needs to be done
c.
Jumping in to provide patient comfort
d.
Being there without an identified goal
ANS: A
Providing presence is a person-to-person encounter conveying closeness and a sense of caring. “Being there” seems to depend on the fact that a nurse is attentive to the patient more than the task. “Being with” means being available and at the patient’s disposal. If the patient accepts the nurse, the nurse will be invited to see, share, and touch the patient’s vulnerability and suffering. Jumping in may not be welcomed. Being there is something the nurse offers to the patient with the purpose of achieving some goal, such as support, comfort, or encouragement.
The patient is to have thoracentesis at the bedside but tells the nurse that he is afraid and would like to cancel. The nurse sits with the patient and asks him to describe his fears. She then explains the procedure and assures the patient that she will be with him during the procedure. The patient agrees to have the procedure, and during the procedure, the nurse stays with the patient, explaining each step and providing encouragement. How has the nurse helped this patient?
a.
Providing a presence
b.
Listening
c.
Providing touch
d.
Providing family care
ANS: A
The nurse’s presence helps to calm anxiety and fear related to stressful situations. Giving reassurance and thorough explanations about a procedure, remaining at the patient’s side, and coaching the patient through the experience all convey a presence that is invaluable to the patient’s well-being. Listening and touch can be part of the “presence” but are not its entirety. No family was involved in this scenario.
The nurse has cared for a patient for several days. The patient is terminal and is very near death. The nurse notices the heart rate on the monitor decreasing and then the absence of a pattern. The family is standing at the patient’s bed, and when the nurse checks the patient and finds no pulse or blood pressure, the family begins sobbing and hugging each other. Some hold the patient’s hand. The nurse is overwhelmed by the presence of grief and leaves the room to cry in the nurses’ lounge. What is the nurse demonstrating?
a.
Task-oriented touch
b.
Caring touch
c.
Protective touch
d.
None of the above
ANS: C
When a nurse withdraws or distances herself or himself from a patient when the nurse is unable to tolerate suffering or needs to escape from a situation that is causing tension, the nurse is practicing a form of protective touch that is used to protect the nurse emotionally. Task-oriented touch is done when performing a task or procedure. Caring touch is a form of nonverbal communication that influences a patient’s comfort and security, enhances self-esteem, and improves reality orientation.
When dealing with the concept of “touch,” the nurse realizes what with regard to contact touch?
a.
Involves only skin-to-skin contact
b.
Involves eye contact
c.
Occurs only when tasks are being performed
d.
Is used only to protect the patient
ANS: A
Contact touch involves obvious skin-to-skin contact, whereas noncontact touch refers to eye contact. It is difficult to separate the two. Touch that occurs when tasks are being performed is known as “task-oriented touch.” Touch used to protect the patient or nurse is known as “protective touch.” Although contact touch does include task-oriented and protective touch, these are not the only forms of touch.
The nurse is caring for a patient who has been sullen and quiet for the past three days. Suddenly, he says, “I’m really nervous about surgery tomorrow, but I’m more worried about how it will affect my family.” What should the nurse do?
a.
Assure the patient that everything will be all right and continue what she/he is doing.
b.
Tell the patient that whatever happens is out of his control, so he shouldn’t worry.
c.
Stop what he/she is doing (if possible) and ask the patient to expand on his statement.
d.
Contact hospital clergy to come and talk with the patient.
ANS: C
A nurse needs to be able to give patients full, focused attention as they tell their stories. It is easy to become distracted by tasks at hand, colleagues shouting instructions, or other patients waiting to have their needs met. However, the time taken to listen effectively is worthwhile both in the information gained and in strengthening of the nurse-patient relationship. Although contacting clergy could be an appropriate measure for this patient, the nurse should first listen to what the patient is saying. By observing expressions and body language of the patient, the nurse will find cues to assist the patient in exploring ways to achieve greater peace.
The patient is about to undergo a certain procedure and has voiced concern about outcomes and prognosis. The nurse caring for the patient underwent a similar procedure a few years earlier and stops to listen to the patient’s concerns. Which of the following responses by the nurse may be most beneficial?
a.
“I had a similar procedure last year and I can tell you what I went through.”
b.
“I don’t think you have anything to worry about. They do lots of these.”
c.
“If you’re really concerned, I can call the doctor and cancel the procedure.”
d.
“Of course there are no guarantees, but I think you’ll be all right.”
ANS: A
When an ill person chooses to tell his story, it involves reaching out to another human being. Telling the story implies a relationship that develops only if the clinician exchanges his or her stories as well. Professionals do not routinely take seriously their own need to be known as part of a clinical relationship. Yet, unless the professional acknowledges this need, there is no reciprocal relationship, only an interaction. Offering reassurances or offering to cancel the procedure does not open up that relationship. B, C, and D all dismiss the patient’s concerns.
The nurse is making her first set of rounds in the morning. In doing so, she meets a patient whom she has never worked with before. She introduces herself and explains the plan of the day. She also asks the patient how he normally takes his morning medications, such as before breakfast, after breakfast, or during breakfast. She does this because most of the morning medications in that institution are scheduled by pharmacy for 0900. Getting to know her patient will allow her to
a.
Choose the most appropriate time to give the medication.
b.
Explain to the patient that he will not get his medication at his usual time.
c.
Know what information to put on the medication error report form.
d.
Evaluate whether or not the patient is taking his medication correctly at home.
ANS: A
“Knowing the patient” is at the core of the process nurses use to make clinical decisions. Knowing when the patient normally takes his medication will allow the nurse to keep him on as near normal a schedule as possible. Nothing in this question infers that the patient will not get his medications on time, or that a medication error report will need to be completed. Although the nurse can be using this opportunity to evaluate whether or not the patient is taking the medication correctly at home, the main purpose, within this context, is to determine the most appropriate time to administer the medication.
Caring is a universal phenomenon that influences the ways in which people (Select all that apply.)
a.
Learn.
b.
Think.
c.
Believe.
d.
Feel.
e.
Behave.
ANS: B, D, E
Caring is a universal phenomenon that influences the ways in which people think, feel, and behave in relation to one another. How people learn and what they believe involve other concepts such as teaching/learning and ethics.
The concept of “knowing” the patient comprises both the nurse’s understanding of a specific patient and the nurse’s subsequent selection of interventions. To know a patient means that the nurse (Select all that apply.)
a.
Avoids assumptions.
b.
Focuses on the patient.
c.
Engages in a caring relationship.
d.
Forms the relationship quickly.
ANS: A, B, C
To know a patient means that the nurse avoids assumptions, focuses on the patient, and engages in a caring relationship with the patient that reveals information and cues that facilitate critical thinking and clinical judgments. Knowing develops over time as a nurse learns the clinical conditions within a specialty and the behaviors and physiological responses of patients.
Despite significant improvements in the overall health status of the U.S. population over the past few decades, disparities among ethnic and racial minorities have
a.
Decreased as education levels equal those of non-Hispanic whites.
b.
Disappeared in relation to non-Hispanic white populations.
c.
Remained a serious challenge locally and nationally.
d.
Decreased faster than anticipated.
ANS: C
Despite significant improvements in the overall health status of the U.S. population over the past few decades, the persistence of disparities in health status among ethnic and racial minorities continues to be a serious local and national challenge. Hispanics, African Americans, and some Asian subgroups are less likely than non-Hispanic whites to have a high school education and often experience poorer access to care and lower quality of preventive, primary, and specialty care.
Eliminating disparities in the health status of people from diverse racial, ethnic, and cultural backgrounds has become one of the two most important priorities of Healthy People 2020 because populations with health disparities have
a.
Increased incidence of disease.
b.
Lower levels of morbidity.
c.
Lower mortality rates.
d.
Decreased incidence of disease.
ANS: A
Populations with health disparities have a significantly increased incidence of disease or increased morbidity and mortality when compared with the general population.
According to the Office of Minority Health (OMH), the thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups are known as
a.
Culture.
b.
Subculture.
c.
Ethnicity.
d.
Cultural backlash.
ANS: A
The OMH describes culture as the thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Subcultures represent various ethnic, religious, and other groups with distinct characteristics from the dominant culture. Ethnicity refers to a shared identity related to social and cultural heritage such as values, language, geographical space, and racial characteristics. Cultural backlash occurs when an individual rejects a new culture because experience with a new or different culture is extremely negative.
When asked to describe the differences between ethnicity and race, what should the student nurse explain?
a.
Ethnicity refers to a shared identity, whereas race is limited to biological attributes.
b.
Ethnicity and race are actually the same and are based in cultural norms.
c.
Ethnicity can be understood only through an ethic worldview.
d.
Race refers to a shared identity, whereas ethnicity is limited to biological attributes.
ANS: A
Ethnicity refers to a shared identity related to social and cultural heritage such as values, language, geographical space, and racial characteristics. Ethnicity is different from race, which is limited to the common biological attributes shared by a group such as skin color or blood type. In any intercultural encounter, there is an insider or native perspective (ethic worldview) and an outsider’s perspective (ethic worldview). Ethnicity is best understood by those who are a part of that ethnicity and have an “emic” worldview.
Care that includes the nurse learning about cultural issues involved in the patient’s health care belief system and enable patients and families to achieve meaningful and supportive care is known as
a.
Ethnocentrism.
b.
Culturally competent care.
c.
Cultural imposition.
d.
Culturally congruent care.
ANS: B
The goal of transcultural nursing is culturally congruent care, or care that fits the person’s valued life patterns and set of meanings. Culturally competent care reflects the ability of a nurse to bridge cultural gaps in caring and enables patients and families to achieve meaningful and supportive caring. It is a step toward reaching culturally congruent care. Ethnocentrism is a tendency to hold one’s own way of life as superior to those of others. It is the cause of biases and prejudices. Cultural imposition is the use of one’s own values and lifestyles as the absolute guide in dealing with patients and interpreting behaviors.
The nurse is caring for a Native American who has had recent surgery. In the patient’s culture, it is a sign of weakness to complain of pain. In the nurse’s culture, people who are having pain ask for pain medicine. The nurse has assumed that the patient has not been having pain and does not need medication because he has not complained of pain. What is the nurse doing?
a.
Utilizing cultural imposition by not asking the patient about his pain
b.
Striving to provide culturally congruent care by allowing the patient to suffer
c.
Operating from an emic worldview of the patient’s cultural beliefs
d.
Practicing discrimination by not giving the patient pain medicine
ANS: A
Health care practitioners who have cultural ignorance or cultural blindness about differences generally resort to cultural imposition and use their own values and lifestyles as the absolute guide in dealing with patients and interpreting their behaviors. Culturally competent care is the care provided by the nurse who attempts to bridge cultural gaps in caring, work with cultural differences, and enable patients and families to achieve meaningful and supportive caring. The nurse in this case has not been able to do this. Any intercultural encounter consists of an inside or native perspective (emic worldview) and an outsider’s perspective (ethic worldview). The nurse is obviously utilizing an ethic worldview. The nurse may be acultural, but she/he did not purposefully ignore the patient’s need.
In performing a cultural assessment, knowledge of a patient’s country of origin and its history and ecological contexts is known as
a.
Ethnohistory.
b.
Biocultural history.
c.
Social organization.
d.
Religious and spiritual beliefs.
ANS: A
Knowledge of a patient’s country of origin and its history and ecological contexts is significant to health care and is known as ethnic heritage and ethnohistory. Biocultural history identifies a patient’s health risks related to the ecological context of the culture. Social organization refers to units of organization in a cultural group defined by kinship status and appropriate roles for their members. Religious and spiritual beliefs are major influences in the patient’s worldview about health and illness, pain and suffering, and life and death. Nurses need to understand the emic perspective of their patients.
The nurse is caring for a patient of Asian descent who speaks very little English. The nurse is especially concerned and attempts to develop a trusting relationship with the patient. She does this knowing that
a.
Cultural assessment needs to be done quickly to provide the best care early.
b.
Miscommunication cannot be tolerated in cultural assessment.
c.
The goal is to get the patient to conform to American health care norms.
d.
Cultural assessment is intrusive in contrast to other types of interviews.
ANS: D
In contrast to other types of interviews, cultural assessment is intrusive and time-consuming and requires a trusting relationship between participants. Miscommunication commonly occurs in intercultural interactions as the result of language and communication differences between and among participants, as well as differences in interpreting each other’s behaviors. The goal is to generate knowledge about the patient’s values, beliefs, and practices about nursing and health care.
The nurse is caring for a patient who has emigrated from another country. The patient is in need of abdominal surgery but seems reluctant to sign the surgical permits. What is one tactic that the nurse should use?
a.
Determine the family social hierarchy.
b.
Encourage the patient to sign the permits.
c.
Call the physician so that surgery can be canceled.
d.
Impress on the patient that her life is in jeopardy.
ANS: A
Nurses should determine the family social hierarchy as soon as possible to prevent offending patients and their families. Working with established family hierarchy prevents delays and achieves better patient outcomes. Encouraging the patient to sign against her social beliefs can cause familial strife. Explaining the level of jeopardy may create undue stress. Nurses should be able to determine the correct hierarchy and should not involve the physician at this time.
The nurse is caring for a Chinese patient who is reluctant to answer questions about her health background. The nurse asks the patient if she would like her husband present when health questions are asked. The nurse does this knowing that the Chinese culture is a collectivistic and patrilineal culture. What does this mean?
a.
Kinship extends to both the father’s side and the mother’s side of the family.
b.
Kinship is limited to the side of the father.
c.
Kinship is limited to the side of the mother.
d.
The husband becomes part of the wife’s clan after marriage.
ANS: B
In collectivistic cultures, families are made up of distant blood relatives across three generations and fictive or nonblood kin. Kinship extends to both the father’s and the mother’s side of the family (bilineal) or is limited to the side of either father (patrilineal) or mother (matrilineal). Patrilineally extended families exist among Chinese and Hindus, where a woman moves into her husband’s clan after marriage and minimizes ties with her own parents and siblings.
The nurse is caring for a patient who does not speak English. She decides to use an interpreter to explain procedures and to answer questions that the patient may have. In performing the interview, what should the nurse do?
a.
Direct questions to the interpreter to ask the patient.
b.
Disregard the age and gender of the interpreter.
c.
Direct questions to the patient.
d.
Ask the interpreter to ask the patient for clarification at the end.
ANS: C
If the patient needs an interpreter, the nurse should ensure gender, age, and ethnic compatibility of the interpreter with the patient’s preference and the topic of discussion. The nurse should direct questions to the patient and not to the interpreter and should have the interpreter ask the patient for feedback and clarification at regular intervals, not only at the end.
Which statement is true relative to caring for a Hindu patient who is dying?
a.
The family will turn his head eastward or to the right.
b.
A close kin will stay with the patient to hear his last wishes.
c.
Anointing of the sick is a common right of the dying.
d.
The family will place a drop of water on the patient’s lips.
ANS: D
The family of a dying Hindu remains at the bedside to place a drop of the holy water from the River Ganges on the patient’s lips immediately after death to help his or her soul to the next life. The family of a critically ill Jewish patient will turn his or her head eastward or to the right side. A dying Hispanic patient will not be left alone, so that a close kin is able to hear the patient’s wishes, allowing the soul to leave in peace. Anointing of the sick is a Roman Catholic sacrament.
In comparing American culture with Asian cultures, which of the following statements is true?
a.
American culture supports collectivism.
b.
Asian communication can be ambiguous.
c.
American communication patterns downplay autonomy.
d.
Asian communication is direct to avoid conflict.
ANS: B
Among Asian cultures, face-saving communication promotes harmony through indirect, ambiguous communication and conflict avoidance. American culture supports individualism, where people value assertive communication because it manifests the ideals of individual autonomy and self-determination.
When caring for a patient of a different culture, it is important for the nurse to understand that
a.
The nurse should protect the patient from family intrusion in her health care decisions.
b.
Working within the established family hierarchy produces better outcomes.
c.
Women as primary caregivers make independent health decisions.
d.
Gender is not a factor when it comes to role expectations.
ANS: B
Working with established family hierarchy prevents delays and achieves better patient outcomes. Nurses need to determine who has authority for making decisions within the family and how to communicate with the proper individuals. Do not assume that just because the woman is the primary caregiver, she will make decisions independently. Determine the family social hierarchy as soon as possible. Gender also differentiates role expectations.
The nurse is caring for a member of the Jewish faith who needs to undergo a critical procedure on Saturday. The patient is refusing the procedure because it is scheduled to be done on the Sabbath. The nurse impresses on the patient the urgency of the procedure, stating that delaying the procedure would put his life at risk. The patient continues to refuse. What should the nurse do?
a.
Cancel the procedure.
b.
Seek permission from the patient to contact the patient’s rabbi.
c.
Have a family member sign the permit.
d.
Have the procedure done against patient wishes.
ANS: B
Nurses need to identify and contact patients’ religious and spiritual leaders before problems occur. Nurses work with these leaders to mediate in times of crises. Canceling the procedure may occur, but not at this time. Doing so prematurely could lead to the patient’s death. A family member cannot make decisions for a competent patient. Having the procedure done against the patient’s wishes cannot be done.
The nurse is providing diabetic diet teaching to a Hispanic man and his wife. When the nurse is discussing foods that are acceptable, the wife continues to interrupt with statements like, “Oh, he doesn’t eat that,” or, “All he eats is rice and beans.” What should the nurse do?
a.
Ask the wife to leave so he/she can focus on teaching the patient.
b.
Explain how “rice and beans” are not acceptable foods on a diabetic diet.
c.
Provide a diet plan with only food alternatives selected by the patient.
d.
Refer the patient and his wife to a dietitian familiar with Spanish food choices.
ANS: D
The nurse should refer the patient to speak with a dietitian who is familiar with cultural food choices. If possible, he/she should develop a diet plan that includes the patient’s cultural diet preferences and can provide culturally sensitive teaching brochures that describe healthy food choices. Rice and beans may be acceptable alternatives in a balanced diet. The nurse should include people in the family who help shop for and prepare food in the home, along with the wife.
Providing culturally congruent care means providing care that
a.
Fits the patient’s valued life patterns and set of meanings.
b.
Is based on meanings generated by predetermined criteria.
c.
Is the same as the values of the professional health care system.
d.
Holds one’s own way of life as superior to those of others.
ANS: A
The goal of transcultural nursing is culturally congruent care, or care that fits the person’s valued life patterns and set of meanings. Patterns and meanings are generated from people themselves, rather than from predetermined criteria. Culturally congruent care is sometimes different from the values and meanings of the professional health care system. Ethnocentrism is a tendency to hold one’s own way of life as superior to those of others. It is not part of culturally congruent care.
Leininger (1991) identified three nursing decision and action modes to achieve culturally congruent care. These modes are “cultural care preservation or maintenance,” “cultural care accommodation,” and “cultural care repatterning.” When assessing patients during the admission process, the nurse utilizes
a.
These action modes in a distinct order.
b.
These action modes individually, one at a time.
c.
Only one action mode per patient.
d.
All these action modes simultaneously.
ANS: D
Nurses are able to use any or all of these action modes simultaneously. These actions require that nurses have knowledge of the patient’s culture and have the willingness, commitment, and skills to work with patients and families in decision making. The outcome sought through these actions and decisions is meaningful, supportive, and facilitative care as judged by the patient.
Compare the following statements. Which are considered predominant in non-Western cultures? (Select all that apply.)
a.
Causes of illness are biomedical in nature.
b.
Illness is an imbalance between humans and nature.
c.
Caring patterns are based in self-care and self-determination.
d.
Diagnoses are described as holistic.
e.
Treatment of disease can be magico-religious based.
ANS: B, D, E
Many non-Western cultures see the cause of illness as being an imbalance between humans and nature. Method of diagnosis is described as holistic, and treatment of illness is mixed to include magico-religious, supernatural herbal, biomedical, etc. Western cultures view the cause of illness as biomedical using scientific, high-tech methods of diagnosis.
Foster (1976) identified two distinct categories of healers cross-culturally. Of the following characteristics, which are congruent with the healing practices of naturalistic practitioners? (Select all that apply.)
a.
Illness is impersonal and is due to biological forces.
b.
Illness is caused by alterations in the body equilibrium.
c.
Sorcerers can cause health and illness.
d.
Human relationships should be emphasized.
e.
Healing modalities include herbs, massage, and surgery.
ANS: A, B, E
Naturalistic practitioners attribute illness to natural, impersonal, and biological forces that cause alteration in the equilibrium of the human body. Healing emphasizes use of naturalistic modalities, including herbs, chemicals, heat, cold, massage, and surgery. In contrast, personalistic practitioners believe that an external agent, which can be human (i.e., sorcerer) or nonhuman (e.g., ghosts, evil, deity), causes health and illness. Personalistic beliefs emphasize the importance of humans’ relationships with others, both living and deceased, and with their deities.
The word spirituality derives from the Latin word spiritus, which refers to breath or wind. Today, spirituality is
a.
Awareness of one’s inner self and a sense of connection to a higher being.
b.
Less important than coping with the patient’s illness.
c.
Patient centered and has no bearing on the nurse’s belief patterns.
d.
Equated to formal religious practice and has a minor effect on health care.
ANS: A
Today, spirituality is often defined as an awareness of one’s inner self and a sense of connection to a higher being, to nature, or to some purpose greater than oneself. Spirituality is an important factor that helps individuals achieve the balance needed to maintain health and well-being and to cope with illness. It positively affects and enhances health, quality of life, health promotion behaviors, and disease prevention activities. Nurses need an awareness of their own spirituality to provide appropriate and relevant spiritual care to others. The concepts of spirituality and religion are often interchanged, but spirituality is a much broader and more unifying concept than religion. The human spirit is powerful, and spirituality has different meanings for different people.
The nurse is caring for a patient who claims that he does not believe in God, nor does he believe in an “ultimate reality.” The nurse realizes that this patient
a.
Is devoid of spirituality.
b.
Is an atheist/agnostic.
c.
Finds no meaning through relationships with others.
d.
Believes that what he does is meaningless.
ANS: B
Some individuals do not believe in the existence of God (atheist) or believe that there is no known ultimate reality (agnostic). This does not mean that spirituality is not an important concept for the atheist or the agnostic. Atheists search for meaning in life through their work and their relationships with others. Agnostics discover meaning in what they do or how they live because they find no ultimate meaning for the way things are. They believe that people bring meaning to what they do.
The nurse is caring for a patient who is terminally ill with very little time left to live. The patient states, “I always believed that there was life after death. Now, I’m not so sure. Do you think there is?” The nurse states, “I believe there is.” The nurse has attempted to
a.
Strengthen the patient’s religion.
b.
Provide hope.
c.
Support the patient’s agnostic beliefs.
d.
Support the horizontal dimension of spiritual well-being.
ANS: B
When a person has the attitude of something to look forward to, hope is present. Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality. This is not evident here. Agnostics believe that there is no known ultimate reality. This would indicate a lack of belief in life after death. The horizontal dimension of spiritual well-being describes positive relationships and connections people have with others. In this case, the patient is more concerned with the vertical dimension, which supports the transcendent relationship with God or some other higher power.
In discussing spiritual well-being, the nurse identifies that the vertical dimension involves
a.
The positive relationships and connections people have with others.
b.
The transcendent relationship between a person and God.
c.
Confidence in something for which there is no proof.
d.
Providing an attitude of something to live for and look forward to.
ANS: B
The concept of spiritual well-being is often described as having two dimensions. The vertical dimension supports the transcendent relationship between a person and God or some other higher power. The horizontal dimension describes positive relationships and connections people have with others. Faith provides confidence in something for which there is no proof. When a person has the attitude of something to live for and look forward to, hope is present.
The nurse is admitting a patient to the hospital. The patient states that he is a very spiritual person but does not practice any specific religion. The nurse understands that these statements
a.
Are contradictory.
b.
Indicate a strong religious affiliation.
c.
Indicate a lack of faith.
d.
Are reasonable.
ANS: D
These statements are reasonable and are not contradictory. Many people tend to use the terms spirituality and religion interchangeably. Although closely associated, these terms are not synonymous. Religious practices encompass spirituality, but spirituality does not need to include religious practice. When a person has the attitude of something to live for and look forward to, hope is present.
A complex concept that is unique to each individual; is dependent upon a person’s culture, development, life experiences, beliefs, and ideas about life; and is a unifying theme in peoples’ lives is called
a.
Spirituality.
b.
Religion.
c.
Self-transcendence.
d.
Faith.
ANS: A
Spirituality is a complex concept that is unique to each individual; is dependent upon a person’s culture, development, life experiences, beliefs, and ideas about life; and is a unifying theme in peoples’ lives. Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality. Self-transcendence is the belief that there is a force outside of and greater than the person. Faith allows people to have firm beliefs despite lack of physical evidence.
Which of the following statement about religion and spirituality is true?
a.
Religion is a unifying theme in people’s lives.
b.
Spirituality is unique to the individual.
c.
Spirituality encompasses religion.
d.
Religion and spirituality are synonymous.
ANS: B
Spirituality is a complex concept that is unique to each individual. Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality. People from different religions view spirituality differently. Although closely associated, spirituality and religion are not synonymous. Religious practices encompass spirituality, but spirituality does not need to include religious practice.
The nurse creates a referral to pastoral care when he/she realizes that the patient is in need of
a.
Psychiatric care.
b.
Return to religious affiliation.
c.
Spiritual care.
d.
Transfer to the psychiatric unit.
ANS: C
Spiritual care helps people identify meaning and purpose in life, look beyond the present, and maintain personal relationships, as well as a relationship with a higher being or life force. The patient may need psychiatric care and may be transferred to the psychiatric unit, but referral to pastoral care will not provide that. Return to a religious affiliation may follow a return to spiritual health.
The nurse is admitting a patient who is a member of the Seventh Day Adventist religion. The physician has written an order for specific tests to be done the next day, which is Saturday. The nurse should
a.
Discuss the patient’s beliefs about the Sabbath.
b.
Order the tests without questioning.
c.
Inform the physician that the tests cannot be performed.
d.
Reorder the tests for Sunday.
ANS: A
It is essential to consider cultural differences and explore personal preferences when determining nursing interventions to enhance spiritual well-being. Some Seventh Day Adventists may not mind having tests on the Sabbath. Others might. Ordering the tests without questioning may lead to patient refusal later and to wasted resources as well as spiritual distress for the patient. Informing the physician that the tests cannot be performed is premature without speaking with the patient first. It is not in the realm of the nurse to reorder tests. Some tests may be critical and may need to be done on the Sabbath.
The nurse and the patient have the same religious affiliation. Because of this, the nurse
a.
Can assume that they have the same spiritual beliefs.
b.
Should not impose her personal values on the patient.
c.
Must use an assessment tool to assess the patient’s beliefs.
d.
Can skip the spiritual belief assessment.
ANS: B
The nurse can use an assessment tool or direct an assessment with questions based on principles of spirituality, but it is important not to impose personal value systems on the patient. This is particularly true when the patient’s values and beliefs are similar to those of the nurse because it then becomes very easy to make false assumptions. It is important to conduct the spiritual belief assessment; conducting an assessment is therapeutic because it expresses a level of caring and support.
When caring for a terminally ill patient, the nurse should focus on the fact that
a.
Spiritual care is possibly the least important nursing intervention.
b.
Spiritual needs often need to be sacrificed for physical care priorities.
c.
The nurse’s relationship with the patient allows for an understanding of patient priorities.
d.
Members of the church or synagogue play no part in the patient’s plan of care
ANS: C
The nurse’s relationship with the patient allows the nurse to understand the patient’s priorities. Spiritual priorities do not need to be sacrificed for physical care priorities. When a patient is terminally ill, spiritual care is possibly the most important nursing intervention. If the patient participates in a formal religion, involve in the plan of care members of the clergy or members of the church, temple, mosque, or synagogue.
The patient is admitted with chronic back pain. The nurse who is caring for this patient should
a.
Focus on finding quick remedies for the back pain.
b.
Look at how pain influences the patient’s ability to function.
c.
Realize that the patient’s only goal is relief of the back pain.
d.
Help the patient realize that there is little hope of relief from chronic pain.
ANS: B
Do not just look at the patient’s back pain as a problem to solve with quick remedies, but rather look at how the pain influences the patient’s ability to function and achieve goals established in life (not just pain relief). Mobilizing the patient’s hope is central to a healing relationship.
In caring for the patient’s spiritual needs, the nurse understands that
a.
Establishing presence is part of the art of nursing.
b.
Presence involves “doing for” the patient.
c.
A caring presence involves listening to the patient’s wishes only.
d.
The nurse must use her expertise to make decisions for the patient.
ANS: A
Establishing presence is part of the art of nursing. Presence involves “being with” a patient versus “doing for” a patient. Demonstrate a caring presence by listening to the patient’s concerns and willingly involving family in discussions about the patient’s health. Show self-confidence when providing health instruction, and support patients as they make decisions about their health.
The patient is in the intensive care unit (ICU), which has strict posted visiting hours and limits the number of visitors to two per patient at any one time. The patient is asking to see his wife and two daughters. The nurse should
a.
Tell the patient that they will be allowed to visit at the appropriate time.
b.
Allow the wife and one daughter to enter the ICU, but not the other daughter.
c.
Allow the two daughters to visit, and let the wife visit when they leave.
d.
Allow the wife and daughters to visit at the patient’s request.
ANS: D
Use of support systems is important in any health care setting. When patients depend on family and friends for support, encourage them to visit the patient regularly. As long as no interference with active patient care is involved, there is no reason to limit visitation.
The nurse is caring for a patient who has been diagnosed with a terminal illness. The patient states, “I just don’t feel like going to work. I have no energy, and I can’t eat or sleep.” The patient shows no interest in taking part in his care. The nurse should
a.
Not be concerned about self-harm because the patient has not indicated any desire toward suicide.
b.
Ignore individual patient goals until the current crisis is over.
c.
Encourage the patient to purchase over-the-counter sleep aids to help him sleep.
d.
Assess the potential for suicide and make appropriate referrals.
ANS: D
A decreased appetite and level of energy and not wanting to be involved in care are signs of hopelessness. The nurse should assess for risk of the patient harming himself or others. The nurse should set goals that are important to the patient. Recommending good sleep hygiene habits is more appropriate than giving over-the-counter sleep aids.
The patient is having a difficult time dealing with his AIDS diagnosis. He states, “It’s not fair. I’m totally isolated from my family because of this. Even my father hates me for this. He won’t even speak to me.” The nurse needs to
a.
Assure the patient that his father will accept his situation soon.
b.
Use therapeutic communication to establish trust and caring.
c.
Point out that the patient has no control and that he has to face the consequences.
d.
Tell the patient, “If your father can’t get over it, forget it. You have to move on.”
ANS: B
The nurse needs to use therapeutic communication to establish trust and a caring presence because providing spiritual care requires caring, compassion, and respect. The nurse should not offer false hope. The nurse should help the patient maintain feelings of control. The nurse should encourage renewing relationships if possible and establishing connections with self, significant others, and God.
The nurse is caring for a patient who is in the final stages of his terminal disease. The patient is very weak but refuses to use a bedpan, and wants to get up to use the bedside commode. What should the nurse do?
a.
Explain to the patient that he is too weak and needs to use the bedpan.
b.
Insert a rectal tube so that the patient no longer needs to actively defecate.
c.
Enlist assistance from family members if possible and assist the patient to get up.
d.
Put the patient on a bedpan and stay with him until he is finished.
ANS: C
Establishing presence is part of the art of nursing. Presence involves “being with” a patient versus “doing for” a patient. Demonstrate a caring presence by listening to the patient’s concerns and willingly involving family in discussions about the patient’s health. The nurse should support patients as they make decisions about their health. If at all possible, the nurse should encourage the patient to maintain as much independence as possible. Inserting a rectal tube involves “doing for” instead of “being with.” Placing the patient on the bedpan is against the patient’s wishes and is another form of “doing for.”
In assessing the spiritual health of her patients, the nurse understands that
a.
Spiritual beliefs change as patients grow and develop.
b.
Spiritual health in older adults leads to peace and acceptance of others.
c.
Older adults often express spirituality by focusing on themselves.
d.
The basis of beliefs among older people is focused on one or two factors.
ANS: A
Spiritual beliefs change as patients grow and develop. Health spirituality in older adults leads to peace and acceptance of self. However, older adults often express their spirituality by turning to important relationships and giving of themselves to others. Beliefs among older people vary based on many factors, such as gender, past experience, religion, economic status, and ethnic background.
When evaluating a patient’s risk for spiritual crises, which of the following are part of the evaluation process? (Select all that apply.)
a.
Review the patient’s self-perception regarding spiritual health.
b.
Review the patient’s view of his/her purpose in life.
c.
Discuss with family and associates the patient’s connectedness.
d.
Ask whether the patient’s expectations are being met.
e.
Impress on the patient that spiritual health is permanent once obtained.
ANS: A, B, C, D
One critical thinking model for spiritual health evaluation lists the evaluation process as including a review of the patient’s self-perception regarding spiritual health, the patient’s view of his/her purpose in life, discussion with the family and close associates about the patient’s connectedness, and determining whether the patient’s expectations are being met. Attainment of spiritual health is a lifelong goal.
Spiritual distress has been identified in a patient who has been diagnosed with AIDS. Upon evaluating the following interventions, which are appropriate for the diagnosis of Spiritual distress? (Select all that apply.)
a.
Develop activities to heal body, mind, and spirit.
b.
Assess for potential suicide.
c.
Offer to pray with the patient.
d.
Teach relaxation, guided imagery, and meditation.
e.
Have patient avoid church attendance.
ANS: A, C, D
Interventions that are appropriate for the nursing diagnosis of Spiritual distress include (1) helping the patient develop/identify activities to heal body, mind, and spirit; (2) offering to pray with the patient; and (3) teaching relaxation, guided imagery, and medication. Assessing for potential suicide would be appropriate for the nursing diagnosis of Hopelessness. Attendance at church should be encouraged.
A patient is diagnosed with borderline hypertension and states a desire to make lifestyle changes to avoid needing to take medication. The nurse will recommend which changes?
a. Changing from weight bearing exercise to yoga
b. Decreased fluid intake and increased potassium intake
c. Stress reduction and increased protein intake
d. Weight reduction and decreased sodium intake
ANS: D
Weight loss decreases the stress on the heart and the afterload. Decreasing salt intake decreases the amount of retained fluid. Changing to yoga from weight-bearing exercise, limiting fluids, and increasing potassium are not indicated. Stress reduction is recommended, but increasing protein is not.
A patient has a blood pressure of 135/85 mm Hg on three separate occasions. The nurse understands that this patient should be treated with
a. a beta blocker.
b. a diuretic and a beta blocker.
c. a diuretic.
d. lifestyle changes.
ANS: D
Prehypertension is defined as a systolic pressure of 120 to 139 and a diastolic pressure between 80 and 89. Drug therapy is recommended if the blood pressure is greater than 20/10 over the goal, which would be140/90. Prehypertension is generally treated first with lifestyle changes.
A patient has a blood pressure of 155/95 mm Hg. The nurse understands that this patient’s risk of cardiovascular disease is _____ greater than normal.
a. two times
b. three times
c. four times
d. six times
ANS: C Cardiovascular disease (CVD) risk doubles with each increase of 20/10 mm Hg above normal, starting at 115/75 mm Hg. This patient’s blood pressure is 40/20 above normal, which increases the risk four times. A blood pressure of 135/85 would be two times greater. The patient’s risk would still be four times greater with a blood pressure of 155/70 or 130/95, since systolic and diastolic blood hypertension are each powerful predictors of CVD.
The nurse is caring for an African-American patient who has been taking a beta blocker to treat hypertension for several weeks with only slight improvement in blood pressure. The nurse will contact the provider to discuss
a. adding a diuretic medication.
b. changing to an ACE inhibitor.
c. decreasing the beta blocker dose.
d. doubling the beta blocker dose.
ANS: A
African Americans do not respond well to beta blockers and ACE inhibitors, but do tend to respond to diuretics and calcium channel blockers. Changing to an ACE inhibitor or altering the beta blocker dose are not indicated. Hypertension in African-American patients can be controlled by combining beta blockers with diuretics.
The nurse understands that a medication such as carvedilol (Coreg) may not be effective in an African-American patient because of its effects on
a. cardiac contractility.
b. heart rate.
c. renin release.
d. vascular resistance.
ANS: C
African Americans are more likely to be susceptible to low-renin hypertension. Beta blockers reduce heart rate, contractility, and renin release, and there is a greater hypotensive response in patients with higher renin levels. Changes in heart rate, contractility, and vascular resistance explain why there is some response in this group.
The nurse is preparing to care for a Native-American patient who has hypertension. The nurse understands that which antihypertensive medication would be most effective in this patient?
a. Acebutolol (Sectral)
b. Captopril (Capoten)
c. Carteolol HCl (Cartrol)
d. Metoprolol (Lopressor)
ANS: B
Captopril is an angiotensin II inhibitor. Native-American patients do not respond well to beta blockers. Acebutolol, carteolol, and metoprolol are all beta blockers.
The nurse is caring for an 80-year-old patient who has just begun taking a thiazide diuretic to treat hypertension. What is an important aspect of care for this patient?
a. Encouraging increased fluid intake
b. Increasing activity and exercise
c. Initiating a fall risk protocol
d. Providing a low potassium diet
ANS: C
Older patients experience a higher risk of orthostatic hypotension when taking antihypertensive medications. Fall risk also increases with a need for increased trips to the bathroom. A fall risk protocol should be implemented. Increasing fluids and activity and limiting potassium are not indicated.
The nurse is performing an assessment on a patient who will begin taking propranolol (Inderal) to treat hypertension. The nurse learns that the patient has a history of asthma and diabetes. The nurse will take which action?
a. Administer the medication and monitor the patient’s serum glucose.
b. Contact the provider to discuss another type antihypertensive medication.
c. Request an order for renal function tests prior to administering this drug.
d. Teach the patient about the risks of combining herbal medications with this drug.
ANS: B
Patients with chronic lung disease are at risk for bronchospasm with beta blockers, especially those like propranolol which are non-selective. Beta blockers, with the exception of carvedilol, also decrease the efficacy of many oral antidiabetic medications. The nurse should discuss a change in medications to one that does not carry this risk.
The nurse is admitting a patient who has been taking minoxidil (Loniten) to treat hypertension. Prior to beginning therapy with this medication, the patient had a blood pressure of 170/95 mm Hg and a heart rate of 72 beats per minute. The nurse assesses the patient and notes a blood pressure of 130/72 mm Hg and a heart rate of 78 beats per minute, and also notes a 2.2-kg weight gain since the previous hospitalization and edema of the hands and feet. The nurse will contact the provider to discuss which intervention?
a. Adding hydrochlorothiazide to help increase urine output
b. Adding metoprolol (Lopressor) to help decrease the heart rate
c. Increasing the dose of minoxidil to lower the blood pressure
d. Restricting fluids to help with weight reduction
ANS: A
Minoxidil is a direct-acting vasodilator which can cause sodium and water retention. Combining this drug with a diuretic can help reduce edema by increasing urine output. If the patient were tachycardic, a beta blocker might be added. It is not necessary to increase the minoxidil dose or to restrict fluids.
The nurse is teaching a patient who has hypertension about long-term management of the disease and a beta blocker. The patient reports typically consuming 1 to 2 glasses of wine each evening with meals. How will the nurse respond?
a. “Beta blockers and wine cause a reflex hypertension.”
b. “Four to 6 ounces of wine is considered safe with these medications.”
c. “Wine in moderation helps you relax and get better blood pressure control.”
d. “Wine increases the hypotensive effects of the beta blocker.”
ANS: D
Patients who take beta blockers should avoid all alcohol because it increases the hypotensive effects. It does not cause reflex hypertension.
A patient who has recently begun taking captopril (Capoten) to treat hypertension calls a clinic to report a persistent cough. The nurse will perform which action?
a. Instruct the patient to go to an emergency department because this is a hypersensitivity reaction.
b. Reassure the patient that this side effect is nothing to worry about and will diminish over time.
c. Schedule an appointment with the provider to discuss changing to an angiotensin II receptor blocker (ARB).
d. Tell the patient to stop taking the drug immediately since this is a serious side effect of this drug.
ANS: C
An angiotensin-converting enzyme (ACE) inhibitor, such as captopril, can cause a constant, irritated cough. The cough will stop with discontinuation of the drug, and many patients can switch to an ARB medication. It does not indicate a hypersensitivity reaction. The cough will not diminish while still taking the drug. The patient does not need to stop taking the drug immediately.
The nurse is preparing to administer an angiotensin-converting enzyme (ACE) inhibitor to a patient who has hypertension. The nurse notes peripheral edema and swelling of the patient’s lips. The patient has a blood pressure of 160/80 mm Hg and a heart rate of 76 beats per minute. What is the nurse’s next action?
a. Administer the dose and observe carefully for hypotension.
b. Hold the dose and notify the provider of a hypersensitivity reaction.
c. Notify the provider and request an order for a diuretic medication.
d. Request an order for serum electrolytes and renal function tests.
ANS: B
The patient has signs of angioedema which indicates a hypersensitivity reaction. The nurse should hold the dose and notify the provider. Giving the dose will make the reaction more serious. These are not signs of edema, so a diuretic is not indicated. Electrolytes and renal function tests are not indicated.
The nurse is caring for a patient who will begin taking captopril (Capoten) for hypertension. The nurse reviews the patient’s laboratory test results and notes increased BUN and creatinine. Which action will the nurse take?
a. Administer the captopril and monitor vital signs.
b. Contact the provider to discuss changing to fosinopril (Monopril).
c. Obtain an order for intravenous fluids to improve urine output.
d. Request an order to add hydrochlorothiazide (HydroDIURIL).
ANS: B
Patients who have renal insufficiency will not require a decrease in dose with fosinopril, as they would with other angiotensin-converting enzyme (ACE) inhibitors. If captopril is given, it should be given in a reduced dose. Increased IV fluids are not indicated.
The nurse is caring for a patient who experiences a rapid rise in blood pressure. The nurse will contact the provider to discuss administering which medication?
a. Amlodipine (Norvasc)
b. Nifedipine (Procardia)
c. Nifedipine extended release (Procardia XL)
d. Verapamil (Calan)
ANS: B
The short-acting nifedipine is used to treat rapid rises in blood pressure but cannot be used for out-patient treatment at high dosages because of an increased risk for sudden cardiac death. The other drugs are not used for rapid rise in BP.
The nurse is caring for a 70-year-old patient who has recently begun taking amlodipine (Norvasc) 5 mg/day to control hypertension. The nurse notes mild edema of the patient’s ankles, a blood pressure of 130/70 mm Hg, and a heart rate of 80 beats per minute. The patient reports flushing and dizziness. The nurse will notify the provider and
a. ask to decrease the dose to 2.5 mg/day.
b. discuss twice daily dosing.
c. request an order for a diuretic.
d. suggest adding propranolol to the regimen.
ANS: A
This patient is experiencing side effects of the medication. Elderly patients often require lower doses, so the nurse should ask about a dose reduction. Older adults generally require 2.5 to 5.0 mg/day. Twice daily dosing is not recommended. Unless edema persists, a diuretic is not indicated.
The nurse teaches a patient about antihypertensive medication. Which statements by the patient indicate understanding of the teaching? (Select all that apply.)
a. “I should be careful when I stand up from a chair.”
b. “I should not add extra salt to my foods.”
c. “If I have side effects, I should stop taking the drug immediately.”
d. “If my blood pressure returns to normal, I can stop taking this drug.”
e. “I may need to take a combination of drugs, including diuretics.”
f. “I will not need to make lifestyle changes since I am taking a medication.”
ANS: A, B, E
The patient receiving an antihypertensive medication should be warned to rise slowly to avoid orthostatic hypotension. Patients should be counseled to continue to make lifestyle changes, including decreasing sodium. Often, more than one medication is required. Patients should not stop taking the drug abruptly to avoid rebound hypertension and will not stop the drug when blood pressure returns to normal.
The nurse is preparing to administer the first dose of hydrochlorothiazide (HydroDIURIL) 50 mg to a patient who has a blood pressure of 160/95 mm Hg. The nurse notes that the patient had a urine output of 200 mL in the past 12 hours. The nurse will perform which action?
a. Administer the medication as ordered.
b. Encourage the patient to drink more fluids.
c. Hold the medication and request an order for serum BUN and creatinine.
d. Request an order for serum electrolytes and administer the medication.
ANS: C
Thiazide diuretics are contraindicated in renal failure. This patient has oliguria and should be evaluated for renal failure prior to administration of the diuretic—especially in the absence of known renal failure for this patient. Drinking more fluids will not increase urine output in patients with renal failure.
The nurse is preparing to administer doses of hydrochlorothiazide (HydroDIURIL) and digoxin (Lanoxin) to a patient who has heart failure. The patient reports having blurred vision. The nurse notes a heart rate of 60 beats per minute and a blood pressure of 140/78 mm Hg. Which action will the nurse take?
a. Administer the medications and request an order for serum electrolytes.
b. Give both medications and evaluate serum blood glucose frequently.
c. Hold the digoxin and notify the provider.
d. Hold the hydrochlorothiazide and notify the provider.
ANS: C
When thiazide diuretics are taken with digoxin, patients are at risk of digoxin toxicity because thiazides can cause hypokalemia. The patient has bradycardia and blurred vision, which are both signs of digoxin toxicity. The nurse should hold the digoxin and notify the provider. Serum electrolytes may be ordered, but the digoxin should not be given.
The nurse is teaching a patient about taking hydrochlorothiazide. Which statement by the patient indicates a need for further teaching?
a. “I may need extra sodium and calcium while taking this drug.”
b. “I should eat plenty of fruits and vegetables while taking this medication.”
c. “I should take care when rising from a bed or chair when I’m on this medication.”
d. “I will take the medication in the morning to minimize certain side effects.”
ANS: A
Patients do not need extra sodium or calcium while taking thiazide diuretics.
Thiazide diuretics can lead to hypokalemia, so patients should be counseled to eat fruits and vegetables that are high in potassium. Patients can develop orthostatic hypotension and should be counseled to rise from sitting or lying down slowly. Taking the medication in the morning helps to prevent nocturia-induced insomnia.
